Intellectual Disability and

La nguage D i s o rd er
a, b
Natasha Marrus, MD, PhD *, Lacey Hall, MS

KEYWORDS
 Intellectual disability  Global developmental delay  Language disorder
 Early intervention  Multidisciplinary care

KEY POINTS
 Intellectual disability (ID) and language disorders are neurodevelopmental conditions
arising in early childhood.
 Child psychiatrists are likely to encounter children with ID and language disorders
because both are strongly associated with challenging behaviors and mental disorders.
 Because early intervention is associated with optimal outcomes in ID and language disor-
ders, child psychiatrists must be aware of their signs and symptoms, particularly as
related to delays in cognitive and adaptive function.
 Optimal management of both ID and language disorders requires a multidisciplinary,
team-based, and family centered approach. Child psychiatrists play an important role
on this team, given their expertise with contextualizing and treating challenging
behaviors.

INTRODUCTION

Among parents’ foremost developmental concerns are cognitive delays, in particular

delays in language and adaptive function. Both are features of intellectual disability
(ID), or, when language is specifically affected, language disorders. Child psychiatrists
frequently encounter these conditions, particularly because they are associated with
an increased risk of challenging behaviors and mental disorder. In working with
affected children and their families, child psychiatrists should be prepared to identify
relevant signs and symptoms, manage psychiatric comorbidities, refer to specialists
for comprehensive assessment and multidisciplinary treatments, and foster family-
centered care. Child psychiatrists thus play an important role in addressing the multi-
faceted nature of these conditions and in optimizing independence and functional
outcomes.

a
Department of Psychiatry, Division of Child and Adolescent Psychiatry, Washington University
in St Louis, 660 South Euclid Avenue, Box 8504, St Louis, MO 63110, USA; b Department of Psy-
chology, St. Jude Children’s Research Hospital, 262 Danny Thomas Place, Memphis, TN
38105, USA
* Corresponding author.
E-mail address: Natasha@wustl.edu

Child Adolesc Psychiatric Clin N Am 26 (2017) 539–554

http://dx.doi.org/10.1016/j.chc.2017.03.001 childpsych.theclinics.com
1056-4993/17/ª 2017 Elsevier Inc. All rights reserved.
540 Marrus & Hall

INTELLECTUAL DISABILITY

ID is a neurodevelopmental disorder characterized by 3 features1:

 Deficits in cognition
 Deficits in adaptive function
 Onset during the developmental period
Collective attitudes toward ID have shifted from a model of static deficiencies to a
more dynamic, strength-based perspective, and so-called mental retardation, the
prior diagnostic term, has fallen out of favor. The introduction of the term “Intellectual
Disability” in Diagnostic and Statistical Manual of Mental Disorders, Fifth edition
(DSM-5) was presaged by Rosa’s Law, a 2010 federal statute requiring that ID replace
mental retardation in health, legal, and educational policy (P.L. 111–256). Also, in
contrast with DSM-4–Text Revision, absolute intelligence quotient (IQ) cutoffs no
longer define severity; mild, moderate, severe, or profound ID is now classified by level
of adaptive functioning within a range of IQ scores. Adaptive functioning encom-
passes 3 domains:
 The conceptual domain, which includes language, knowledge, and memory
 The social domain, which includes empathy, social judgment, and rule-following
ability
 The practical domain, which includes self-care, organization, and daily living
skills
Estimates of ID range between 1% and 3%, with a male/female ratio of 1.6:1.2
Causes of ID include genetic abnormalities, as well as prenatal, perinatal, and post-
natal environmental factors3,4 (Fig. 1). Suspicion of ID can arise during infancy,
although children less than 5 years of age are typically diagnosed with global

Fig. 1. Causes of ID and their respective percentages4 are shown, together with a list of
currently recommended genetic testing. Several non-genetic factors also lead to ID,
including congenital infections, exposures to teratogens or toxins, prematurity, hypoxia,
trauma, intracranial hemorrhage, central nervous system infection or malignancy, psychoso-
cial deprivation, malnutrition, or acquired hypothyroidism. CpG, cytosine-phosphate-gua-
nine; GAA, guanidinoacetate; MECP2, methyl-CpG binding protein 2. (Information from
Moeschler JB, Shevell M. Comprehensive evaluation of the child with intellectual disability
or global developmental delays. Pediatrics 2014;134(3):e903–18; and Pivalizza P, Lalani SR.
Intellectual disability in children: evaluation for a cause. UpToDate: Waltham (MA); 2016.)
 Intellectual Disability and Language Disorder 541

developmental delay, which requires delays in 2 or more functional domains associ-

ated with intellectual and adaptive impairment and which shows some correlation
with ID. ID can be determined with greater certainty by age 5 years, when cognitive
abilities become more stable. Children with less severe ID may not be diagnosed until
school age, when academic demands highlight weaknesses in cognition.5 Outcomes
vary depending on severity: individuals with mild ID may achieve some signs of inde-
pendence, such as having a job or starting a family,6 although more severe ID requires
long-term community supports for housing, occupational activities, and recreational
activities.

Evaluation
A comprehensive history entails a birth/prenatal history; family history; 3-generation
pedigree; and information on the course and timing of delays in language, motor,
social-emotional, and adaptive functioning.7 Children with ID may have a history of de-
lays in talking, sitting up, crawling, or walking; immature play and social interaction;
and poor comprehension, learning, and problem solving. Screening tools, such as
the Ages and Stages Questionnaire,8 can usefully clarify the extent of these concerns
(see Ref.9 for other examples). Frequent neurologic comorbidities, such as seizures
and motor signs (eg, spasticity, ataxia, hypotonia), as well as developmental regres-
sion, should be assessed. Physical examination includes a complete neurologic ex-
amination, measurement of head circumference, and attention to features
associated with genetic syndromes, such as facial dysmorphisms and skin findings.3
A comprehensive evaluation of intellectual and adaptive functioning through neuro-
psychological testing is ultimately necessary for diagnosis.
Medical work-up includes testing for genetic syndromes, metabolic disorders, ac-
quired hypothyroidism, and lead exposure.3 When a genetic syndrome or metabolic
disorder is suspected, referral to a geneticist is recommended to ensure the most
comprehensive testing. A neurology referral is recommended for any neurologic con-
cerns. Brain MRI is advised if microcephaly, macrocephaly, seizures, or neurologic
signs are present.7,10 Children with ID are more likely to have other medical conditions,
including cataracts, vision and hearing impairments, congenital heart disease, consti-
pation, obesity, and sleep disorders, which may prompt additional referrals. Such
comorbidities not only affect overall function and quality of life but can also increase
challenging behaviors.

Differential Diagnosis
The differential diagnosis for ID includes other neurodevelopmental disorders, which
can also be comorbid with ID:
 Autism spectrum disorder (ASD), which has a similar prevalence to ID, and is
characterized by impaired social communication, restricted interests, and repet-
itive behaviors. At least 25% of children with ASD have ID.11
 Language disorders, like ID, feature language delays. The occurrence of lan-
guage delay should prompt investigation of other delays, so that ID is not
overlooked.
 Epilepsy may manifest with delays and regression in core developmental do-
mains, such as language. Behaviors suggestive of epilepsy include staring spells,
shaking spells, and intermittent changes in levels of consciousness with associ-
ated automatisms (eg, blinking, lip smacking).
These potential diagnostic confounds highlight the importance of comprehensive
evaluations and neuropsychological testing.
542 Marrus & Hall

Challenging Behaviors, Comorbidity, and Management

Challenging behaviors are common in ID and can be more strongly associated with
parental stress than the level of cognitive impairment.12 These challenging behaviors
may include noncompliance, property destruction, tantrums, “meltdowns”, and phys-
ical aggression toward self or others. Although challenging behaviors occur in 4% to
9% of typically developing children, they occur in 25% of children with ID.13 A major
factor in ID stems from communication impairment, which limits the ability to express
frustration and/or explain external factors or underlying physical or emotional distress.
Children and adolescents with ID are also known to have a higher prevalence of psy-
chiatric disorders, including attention-deficit/hyperactivity disorder (ADHD), mood dis-
orders, anxiety disorders, and psychotic disorders.14
The psychopharmacologic evidence base is limited in ID, although there is support
for judicious use of medication for disruptive behaviors and psychiatric comorbid-
ities.15,16 Table 1 lists common medication classes, typical uses, side effects, and
suggested monitoring. In preschoolers, behavioral treatment options are first line,

Table 1
Medications for intellectual disability

Medications by Class Target Behaviors Adverse Effects Monitoring

Typical antipsychotics Agitation, aggression, Extrapyramidal AIMS
(eg, haloperidol, hyperactivity, self- symptoms, tardive
chlorpromazine) injury dyskinesia
Atypical Irritability, Weight gain, Blood glucose, HbA1c,
antipsychotics aggressiveness, somnolence, lipids
(eg, risperidone, hyperactivity, self- increased risk of AIMS
aripiprazole, injurious behavior, diabetes,
olanzapine) repetitive behaviors extrapyramidal
symptoms,
akathisia, tardive
dyskinesia
Mood stabilizers Mood lability, Lithium: tremor, renal Renal and thyroid
(eg, lithium, aggression, and thyroid toxicity monitoring for
valproic acid, impulsivity, self- Valproate: tremor, lithium, liver
carbamazepine) injurious behavior sedation, weight function tests,
gain CBC, and ammonia
Carbamazepine: with valproic acid,
nausea, vomiting regular drug levels
for all 3
SSRIs (eg, fluoxetine, Depressed mood, Activation, agitation, None specific
sertraline, anxiety, self- aggression, nausea
fluvoxamine) injurious behavior,
repetitive behaviors
Stimulants (eg, Hyperactivity, Loss of appetite, Height, weight, vital
methylphenidate) inattention, insomnia, depressed signs
impulsivity mood
Alpha-agonists Hyperactivity, Hypotension, Vital signs
(eg, clonidine, inattention, sedation, increased
guanfacine) impulsivity, tics depression

Abbreviations: AIMS, Abnormal Involuntary Movement Scale; CBC, complete blood count; HbA1c,
hemoglobin A1c; SSRI, selective serotonin reuptake inhibitor.
Data from Handen BL, Gilchrist R. Practitioner review: psychopharmacology in children and ad-
olescents with mental retardation. J Child Psychol Psychiatry 2006;47(9):871–82.
 Intellectual Disability and Language Disorder 543

given their effectiveness and more frequent medication side effects in younger chil-
dren. Nevertheless, when safety or ability to engage in therapy are concerns, medica-
tion may be instrumental for successful implementation of a treatment plan and
reducing caregiver stress. Medication is also an element of combined therapy (medi-
cation plus behavioral management), and psychiatrists can guide the appropriate bal-
ance of behavior and medication. Low starting doses are recommended, with slow
titration, along with systematic evaluation of both positive and negative effects in
the context of the entire treatment plan.
Among behavioral treatments, applied behavioral analysis (ABA) has a well-
established evidence base.17 ABA attempts to modify antecedents and/or conse-
quences of specific behaviors, either to discourage a problematic behavior or
encourage an alternative behavior. Functional behavioral analyses provide detailed
measurement of potential instigators of challenging behavior, such as need for atten-
tion or help, escape from demands, attempt to get what is wanted, protest, or self-
stimulation.13 Behavioral planning is then tailored to the child’s behavioral profile
and developmental level. In addition to ABA, parent-training approaches (eg, Stepping
Stones Triple P18 and Parent-Child Interaction Therapy19) show evidence for
improving disruptive behaviors in ID.

Promotion of Developmental Progress

Children with ID/global developmental delay benefit from intensive early intervention
and multidisciplinary services.20 Federal law under the Individuals with Disability Edu-
cation Act mandates that state-run programs identify children with disabilities and
provide developmental services. Before age 3 years, families receive an Individualized
Family Service Plan (IFSP), which implements an individualized program of services
and developmental therapies. These services and therapies may include speech
and language therapy, occupational and physical therapy, psychological and behav-
ioral services, medical services, nutrition counseling, assistive technology, family
counseling and training, home visitation, and social services. The IFSP applies for
ages 0 to 3 years, after which children who qualify for ongoing services are transi-
tioned to an Individual Education Plan (IEP) with multidisciplinary preschool
programming.

LANGUAGE DISORDERS

In DSM-5, language disorders are classified as communication disorders. Communi-

cation comprises all verbal and nonverbal input used to transmit information between
individuals, including language and speech. Language involves conveying information
through the form, content, and function of symbolic systems according to specified
rules (see Fig. 1). Speech is the oral production of language. Delayed talking may
thus reflect disturbances in speech, language, and/or communication. Historically,
language disorders have been referred to by a variety of terms, including develop-
mental language disorders and specific language impairment. The focus here is on
early childhood features of language disorders per DSM-5, which implicate language
form and function (Fig. 2).
Prevalence estimates for language disorder generally range between 3% and
8%,21,22 with a male/female ratio of 1.33:1 in an epidemiologic sample.21 Language
disorders are heritable and generally seem to be polygenic, although some specific
genetic factors, including the FOXP2 gene and linkage markers on chromosomes 3,
6, and 19, have been identified.23 Language disorders can also be acquired secondary
to infection, brain injury, neglect, and abuse.
544 Marrus & Hall

Fig. 2. Language disorders affect 1 or more fundamental aspects of language: form, con-
tent, and function. Deficits may involve morphology (understanding and use of the building
blocks of words), syntax (grammar), and semantics (vocabulary). Phonology, the ability to
distinguish and use speech sounds appropriately, is affected in speech sound disorder. Dis-
orders of pragmatics, the use of language, are encompassed within social communication
(pragmatic) disorder.

Early language difficulties are a risk factor for impaired literacy skills, memory skills,
and nonverbal abilities,24,25 although individual patterns of strengths and weaknesses
in distinct aspects of language may vary over time. In some cases, so-called illusory
recovery occurs,26 whereby a child’s language seems to normalize, but deficits return
with subsequent increases in demands. In addition, rates of language growth may
plateau by early adolescence, increasing the gap between children with and without
language disorders.27 Receptive language impairments have worse prognoses than
expressive language impairments. Deficits of comprehension are less responsive to
therapy and do not resolve spontaneously; they are linked to increased likelihood of
social difficulties,28 struggles with nonverbal reasoning,29 and psychiatric
conditions.30

Language Delay and Late Talkers Versus Language Disorder

Natural variability in language acquisition can make it challenging to assess early de-
lays and to distinguish them from language disorders, which involve more persistent
symptoms. Prevalence of late language emergence in 2-year-old children ranges be-
tween 10% and 20%,31 and boys are 3 times more likely to be affected.32,33 Most of
these children do not ultimately have language disorders.34 This late-talkers group
may have only a few words at age 2 years, but matches peers in expressive language
skills by age 3 years.34,35
Because only some children with late language emergence have language disor-
ders, assessment and management of this group has been debated. Compared
with children who develop language disorders, late talkers use more communicative
gestures,36 are less likely to have receptive language delay,37 and show better recall
 Intellectual Disability and Language Disorder 545

of sentences on standardized testing.38 Nonetheless, toddlers and preschoolers with

late language emergence should be referred to a speech/language therapist, because
they may be at risk for later language and literacy difficulties.39 In the presence of
associated risk factors for language disorders, such as ASD, global developmental
delay, or hearing impairment, direct speech and language services are generally indi-
cated. For children at lower risk, periodic monitoring is recommended, together with
guidance for parents to provide indirect language stimulation (Box 1). If persistent de-
lays or additional developmental concerns arise, a complete assessment and direct
intervention may be warranted.

Evaluation
The history should review not only language development and milestones but also any
other delays, challenging behaviors, mood and anxiety, and trauma that could result in
developmental setbacks. In language disorders, progress is generally slow from the
outset, and regression is uncommon, unlike in ASD.40 Although speech delays
frequently co-occur, they are not a hallmark. Table 2 provides a description of typical
language milestones and clinically significant red flags. Impaired receptive and
expressive language commonly co-occur, and difficulties with comprehension, in
particular, are a red flag for chronic language difficulties.41 The mental status exami-
nation should note form, function, and use of language, including articulation, fluency,
and tone; comprehension; the frequency and complexity of verbal communication;
vocabulary; social reciprocity; and use and responsiveness to nonverbal communica-
tion, such as gestures, body language, and facial expression.
The utility of language screeners has been deemed inconclusive,42 although, in
cases of clinical suspicion, screeners can help index the level of concern. Two acces-
sible parent-report measures are the MacArthur Communicative Development Inven-
tory (M-CDI)43 and the Language Development Survey (LDS).31 The M-CDI features

Box 1
Indirect stimulation of language competence in young children

Responsiveness
 Provide responses directly related to a child’s communication act or focus of attention.
 Follow the child’s lead in play.
 Discuss what the child is doing versus asking lots questions.
Language modeling
 Imitate or expand the child’s actions or words.
 Rephrase what the child says in grammatically correct form.
 Provide examples of using gestures and other nonverbal cues.
Reinforcement of communication
 Provide opportunities to communicate wants and choices rather than anticipate all the
child’s needs.
 Allow adequate time to initiate communication and respond.
 Praise communication attempts.

Data from American Speech-Language-Hearing Association (n.d.). Spoken language disorders

(practice portal). Available at: www.asha.org/Practice-Portal/Clinical-Topics/Spoken-Language-
Disorders/. Accessed October 1, 2016.
 546
Marrus & Hall
Table 2
Language milestones and red flags

Milestones Red Flags

Receptive Expressive Receptive Expressive
12 mo Recognizes words as symbols for First words, communicative games Does not respond to name or No babbling, pointing, gesturing
objects, 3–50 words, recognizes gestures
name
18 mo Words are understood outside 50–100 words, intents include Does not follow 1-step directions No “Ma-ma,” “Da-da,” or other
context of routine games requesting, answering questions, names
acknowledging
2y Single words for objects out of 200–300 words, 2-word utterances, Does not point to pictures or other Does not use at least 25 words
sight telegraphic speech with few body parts when named
grammar markers, symbolic play,
speech is 50% intelligible
2.5 y What/who/where questions Use of questions, early emerging Does not verbally respond or nod/ Does not combine 2 words into
grammar, narratives are shake head to questions unique phrases
primarily labels and descriptions
3y “Why?” questions and basic spatial Simple sentences, narratives are Does not understand prepositions Does not use at least 200 words,
terms (in/on/under); simple time sequences with them but no plot, or action words, does not follow does not ask for things by name,
concepts (eg, tomorrow) speech is 75% intelligible 2-step instructions repeats phrases in response to
questions, unintelligible most of
the time
4y “When/how?” questions, basic Can tell a story, uses conjunctions Poor understanding of instructions Disordered speech, no phrases of
colors, shapes, sizes to conjoin sentences; speech is or question words 5–6 words, echolalia,
100% intelligible unintelligible most of the time
5y Letter names and sounds; numbers Correct use of past tense; uses Poor understanding of instructions Unintelligible most of the time,
and counting conjunction words (when, so, or question words deletes parts of words, echolalia,
because, if); narratives are chains cannot describe short sequences
with some plot of events
Any age Regression or loss of milestones

Data from Chapman R. Children’s language learning: an interactionist perspective. J Child Psychol Psychiatry 2000;41:33–54; and Miller J. Assessing language pro-
duction in children. Boston (MA): Allyn & Bacon; 1981.
 Intellectual Disability and Language Disorder 547

long and short versions (requiring 20 and 5 minutes, respectively) for ages between 8
and 36 months. The LDS, which applies up to 42 months, is embedded in the Child
Behavior Checklist, which conveniently queries general behavioral concerns. It is
also worthwhile to screen for anomalous social development, given the association
of language delay and ASD. Two of the most common brief ASD screeners are the
Modified Checklist for Autism (M-CHAT), for ages 16 to 30 months,44 and the Social
Communication Questionnaire, for ages 4 years and older.45
Medical work-up first involves ruling out hearing conditions, and referral for an
audiological evaluation is an important initial step. An oral-motor evaluation should
be considered if there are phonological concerns, or the child has feeding diffi-
culties or drooling. For laboratory testing, a complete blood count may be consid-
ered to evaluate for anemia, which has been associated with developmental delay,
as well as lead testing.46 Genetic testing is not routine, because there are no com-
mon, strongly associated genetic markers of language disorders,47 but a genetics
referral is advised for features suggesting a genetic syndrome (discussed earlier). In
cases of regression or concern for seizures, rapid referral to a neurologist is
warranted.

Differential Diagnosis
Several conditions may present with communication difficulties in early childhood; in
some cases, these are comorbid with language disorders, so a speech/language
referral remains indicated:
 Hearing impairment: as mentioned earlier, this possibility should be considered
early in the evaluation. For children with ID and impaired language, there is a
risk of reduced hearing over time, and hearing should therefore be monitored.
 ID: language delays frequently occur in ID, although only a subset of individuals
ultimately show deficiencies consistent with a language disorder. Marked lan-
guage problems in individuals with ID should receive comprehensive evaluation
and treatment.
 ASD: language delay and disorders are common in ASD, even when accounting
for pragmatic language issues, which are universal. Consideration of ASD is
important given the strong benefit of early intervention for ASD.
 ADHD: inattention and impulsivity may detract from opportunities to learn and
practice language skills, particularly as related to pragmatics. Children with
ADHD also have higher rates of language disorders.
 Selective mutism: in this condition, poor language output manifests in specific
environments; for example, at school but not at home. Selective mutism is
conceptualized as an anxiety disorder, although speech/language issues often
co-occur.

Challenging Behavior and Comorbidities

Similar to children with ID, children with language disorders are at increased risk of
challenging behaviors and psychiatric comorbidities. Among children with a language
disorder, 40% to 75% show challenging behaviors48 and 30% to 50% have psychi-
atric disorders,49,50 most commonly ADHD, anxiety disorders, conduct disorders,
and mood disorders. Conversely, research suggests that 40% of children with psy-
chiatric diagnoses also have a language impairment.51 Work by Beitchman and col-
leagues52 showed that increased rates of psychiatric diagnoses continue up to early
adulthood, and decreased psychiatric comorbidity was associated with special
education.53
548 Marrus & Hall

Common challenging behaviors include both internalizing and externalizing symp-

toms. Hyperactivity and attentional difficulties are frequently observed,54,55 as well
as shyness, social withdrawal, and poor self-esteem.56 Socioemotional deficits
may also be present, including difficulty inferring emotional reactions57 and regu-
lating emotions.58 As children get older, they may struggle with forming and main-
taining close relationships,59 and are more likely to be bullied60 and experience
abuse.61

Management
Psychiatrists play an important role in managing psychiatric comorbidities, as well as
monitoring progress and coordinating care. In addition to making speech/language re-
ferrals, they can assist families in obtaining an evaluation for an IFSP or IEP and advo-
cate for further services or educational accommodations. Because psychiatrists are in
a position to correlate language function with psychiatric symptoms, they can provide
important contextual information about the relationship between a child’s language
function and associated behavioral concerns. This information may result in more
appropriately structured and targeted behavioral interventions and reduce misattribu-
tions of challenging behavior.62

Language Interventions: Principles, Approaches, and Modalities

Language intervention is intended to enhance language output and comprehension,
ensure access to academic content, and advance communication to the next devel-
opmental level. Principles of effective intervention include language facilitation in the
context of communication; dynamic, generalizable interventions; regular assessment
of response; and adaptation of treatment goals and strategies according to individual
learning style, progress, and needs.63 Early intervention is recommended, because
accelerated language growth tends to occur earlier versus later in childhood,41,64
and interventions implemented at younger ages65 as well as interventions of longer
duration have been shown to be more effective.66 A meta-analysis of speech/lan-
guage therapies supported efficacy in expressive, but not receptive, language impair-
ment, and treatments of more than 8 weeks showed better results.67
Language interventions encompass a variety of approaches, treatment types, and
modalities (Table 3). Therapy should be based on the child’s specific needs and
learning style, as identified by standardized testing, parental concerns, and teacher
input. Targets are identified and learned through drill, repetition, and carryover
tracking. For preschoolers, goals include augmenting vocabulary, conceptual under-
standing, and sentence variety and complexity. Associated communication targets
may involve improving intelligibility and phonological awareness, as well as conversa-
tional and narrative skills. Social skills should also be emphasized, given the known
interrelationship of social and language function.
In preschoolers with emerging language skills, parent-mediated interventions are
often implemented. These interventions confer similar benefit to direct approaches
by speech/language pathologists,67 are well suited to language facilitation in a variety
of naturalistic environments, and offer many opportunities for language input. Among
therapeutic modalities, augmentative and alternative communication has accumu-
lated a large body of evidence, especially in children with developmental delays.68
Some concern has been expressed that augmentative forms of communication may
replace speech entirely and therefore restrict children’s communicative development;
however, prevailing evidence suggests that augmentative communication promotes
language development.
 Table 3
Overview of evidence-based aspects of language interventions

Key Features Comments

Approach
Clinician directed  Clinician specifies treatment type, goals,  Less naturalistic
and reinforcement  Maximize practice of specific targets
Child directed  Clinician provides naturalistic opportunities  Useful when poor compliance with clinician-directed
for a child response approaches
 Clinician follows the child’s lead  Useful for unassertive communicators
Parent mediated  Parents use direct, individualized intervention  Cost-effective
practices with the child  Growing evidence for early intervention
 Increased opportunity for language input
Treatment Type
Behavioral therapies  Use behavioral learning principles  Instructional: discrete trial training
 Increase desired behaviors  Play-based: pivotal response training
 Decrease inappropriate behaviors  Often used in ASD and DD

Intellectual Disability and Language Disorder

Milieu therapy  Therapist elicits and reinforces targeted responses  Evidence in several groups: late talkers, ASD, ID, children from
 Naturalistic settings high-risk and low-income families
 Child may select topic to initiate interaction
Relationship-based  Promotes parent-child interactions  Greenspan/DIR/Floortime encourages interaction through play
approaches  Common in early intervention programs  Used in ASD
Modalities
Augmentative alternative  Supplemental methods to replace speech  Aided symbols: PECS and speech generating devices
communication  Can address impaired production or comprehension  Unaided symbols: manual signs
 Strong evidence in ASD and ID
Computer-based instruction  Computer programs teach language skills  Advantage of higher number of trials than with therapist
 Example: Fast ForWord
Video modeling  Videos show desired behaviors  Parent-mediated example: Hanen Program
 Learners are videotaped
 Practice videos are reviewed

Abbreviations: DD, developmental delay; DIR, Developmental Individual-difference Relationship; PECS, Picture Exchange Communication System.
Data from American Speech-Language-Hearing Association (n.d.). Spoken language disorders (practice portal). Available at: www.asha.org/Practice-Portal/
Clinical-Topics/Spoken-Language-Disorders/. Accessed October 1, 2016.

549
550 Marrus & Hall

SUMMARY
Common Aspects of Managing Intellectual Disability and Language Disorders
Management of ID and language disorders shares several overarching features and
principles. Because comprehensive assessments from other specialties are needed
for diagnosis, sound clinical judgment must be exercised regarding referrals and
following up on recommendations. The long-term impact and early emergence of
these conditions is especially challenging for families; sensitivity and clarity are thus
vital when delivering these diagnoses. Surveillance often occurs via a multidisciplinary
team of speech and language pathologists, behavioral therapists, occupational and
physical therapists, educators, social workers, and others. Maintaining clear commu-
nication and a strength-based perspective is important for implementation of thera-
pies that promote ongoing learning and gains in adaptive function. In addition, the
importance of culturally sensitive, family-centered care is increasingly emphasized.
By respectfully listening to families, psychiatrists can ensure that their preferences
and priorities contribute to treatment planning.
Future Directions
Although early childhood mental health and neurodevelopmental disorders are
increasingly recognized, concerns remain for delays in diagnosis.69,70 Development
of improved screeners and expanded training for child psychiatrists in neurodevelop-
mental disorders71 are worthwhile public health considerations to promote earlier
identification and management. Further research on evidence-based treatment is
also a priority, because extant literature frequently involves small samples or less
rigorous study designs. Translational research in genetics, as well as neuroscience,
will be important to elucidate mechanisms by which cognitive impairments interact
with risk for mental disorder, thereby improving diagnostic sensitivity, treatments,
and prevention.

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