Features
Shy or not? Common misunderstandings about possible language disorders

by Shann Hwa (Abraham) Hwang, Wendy K. Lee, and Isaiah M. Hwang

Editor’s note: The main purpose of this article is to increase awareness of possible language disorders in young children. It is not intended to be used for diagnosis. In this paper, the words disorder and impairment are used interchangeably.

Jason, a 3-year old boy, usually prefers to play by himself both at home and at his preschool. He does not make conversation while playing with peers and does not respond with clear words. He prefers to play independently in both solitary play and parallel play. Most of the time, he is a pleasant boy who displays a positive attitude when playing next to his friends.

Is he a typical shy boy, or is it possible that he may have some underlying issue?

Using language in play
To better understand Jason’s play, we need to remember that learning language is an essential development task for preschool children (Conti-Ramsden & Durkin, 2012). In the process of learning language, a child must develop the ability to produce as well as understand language appropriately. To young children, one of the fundamental and foremost ways to develop their language skills is through play.

Various types of play serve as useful tools for them to explore, learn, and develop meaningful ideas in their interaction with others before starting formal education. On the surface, young children at play seem to be doing simple activities independently or with peers.

But play to young children is more than engaging in simple activities. Developmentally speaking, play helps young children explore their physical capabilities, develop their problem-solving skills, expand their language skills by talking to each other, and learn to understand their role in an activity.

Children’s play can be classified in stages, as identified by Mildred Parten (Berger, 2014). In most cases, children younger than 2 years usually engage in solitary play, for example, while 6-year olds tend to play more cooperatively. Their social play enables young children to get to know themselves and others through meaningful interactions.

Language is an essential part in this process. For example, three young children who are building with blocks are using language skills (“What are we building?”), problem-solving skills (“How can we make this tower stand?”), and social-emotional expressions (“Wow, it looks great!”). In this meaningful process, each child needs to comprehend what is being said and to express to others what is in his or her mind in order to achieve their goal altogether. Although playtime may be perceived as downtime or less important by some adults, it actually involves a lot of complex linguistic and cognitive skills.

What if we observe children using low-level language skills in their play? At least one study (Thiemann-Bourque, Brady, & Fleming, 2012) has found a correlation between play, language, and developmental delays.

Language impairment and possible causes
According the American Speech-Hearing-Language Association (n.d.), language can be divided into two aspects: receptive (understanding what is being said) and expressive (sharing thoughts and ideas). Language skills involve not only hearing and speaking words but also using and understanding words and meaning in context (Center for Parent Information and Resources, 2015).

When a young child is not able to produce sounds of spoken language accurately and smoothly, this child may have a speech disorder. On the other hand, when a child cannot understand others (receptive language), or share ideas, feelings, and thoughts with others (expressive language), this child may have a language disorder (ASHA, n.d.).

Teachers may find it helpful to know possible causes of preschool language disorders. According to the American Speech-Hearing-Language Association (n.d.c), some possible causes are as follows:
Other people in your family having language problems 
Being born early 
Low birth weight 
Hearing loss 
Autism 
Down syndrome or Fragile X syndrome 
Fetal alcohol spectrum disorder 
troke 
Brain injury 
Cerebral palsy 
Poor nutrition 
Failure to thrive

It is equally important for teachers to be familiar with specific language impairment (SLI). According to the National Institute on Deafness and Other Communications Disorders (2017), SLI is “a language disorder that delays the mastery of language skills in children who have no hearing loss or other developmental delays. SLI is also called developmental language disorder, language delay, or developmental dysphasia.”

SLI is one of the most common childhood learning disabilities, affecting approximately 7 to 8 percent of children in kindergarten. Its impact can last into adulthood.

Children with SLI are typically late talkers and might not produce any words until age 2 (Conti-Ramsden & Durkin, 2012). At age 3, these children may speak but not be understood by other people. When they get older, children with SLI will have a hard time learning new words and making conversation. Wittke and Spaulding (2018) found that most children with SLI are not identified at the kindergarten level, and it is even less common that preschoolers would be identified and receive intervention.

According to Conti-Ramsden and Durkin (2012), the variation of language development among young children is truly great. This makes the assessment of language and identification of language difficulties and impairment in the early years a considerable challenge.

Parents may begin to worry when their child has not produced single words by age 2. Many children may outgrow language delays (Eisenberg & Guo, 2013), and the likelihood for doing so begins to decrease when children do not catch up by age 3. This marks age 3 as a critical time to identify possible language impairment.

Johnson (2017) stated that most children by age 4 have developed a general sense of how to decode and communicate with language even without formal instruction. They learn how through social interactions with adults and other children. Early onset of language impairment, however, often goes undetected (Skarakis-Doyle, Dempsey & Lee, 2008). In many cases, the comprehension of language in young children is not widely assessed.

Ward and Morris (2006) indicated that comprehension in speech and language difficulties is one of the most common disabilities found in young children. In fact, some young children may have comprehension issues that are masked by other well-intended behaviors.

Common misunderstandings
Teachers and parents may misunderstand children with comprehension difficulties as having personality or behavioral problems. A language impairment inhibits children from expressing what they want to say and understanding what others are saying.

In the classroom, a teacher who wants children to go to a designated area for group time, for example, may use certain hand gestures, tone of voice, or an object in her hand. In such a situation, certain young children may not totally understand what she is saying and yet are able to follow other students or her gestures to join the group.

Sometimes, adults comment on how they perceive specific children and the ways these children interact with others. A few common examples:
“Joey is just too shy. He prefers to play alone. When new kids are around, he does not normally play with them.”
“Sam has a strong head. He insists on doing what he likes. He does not listen to others. When you say one thing, he does another.”
“Susie is a quiet child. She simply does not like to talk. By the way, her parents are that way as well.”

If these perceptions are accurate, the situation is straightforward. But if the behavior masks an undetected, underlying issue, then a child may miss the opportunity to properly develop certain language skills, which in turn may affect future social and emotional development.

A complication arises for teachers working with children whose first language is not English. Arias and Friberg (2017) remind us that cultural and linguistic differences do not lead to language impairment. While it is a challenge to measure the speaking skills of these children (Skahan, Watson, & Lof, 2007), teachers may need to closely monitor their language development and not quickly assume language impairment if a child is still developing his or her language skills in English.

Importance of identification and awareness
When a young child has difficulty pronouncing words, it is fairly easy for parents and teachers to become aware of the issue. Language impairment, however, might not be identified until social and academic performance are negatively affected when a child enters formal education (Zhang & Tomblin, 2000).

Johnson et al. (1999) argued that children with early onset of language impairment showed negative long-term outcomes in language, cognitive, and academic domains compared to their counterparts who do not have the issue.

Early identification offers a great opportunity for early intervention and support and information to parents and teachers. Early intervention provides a preschooler the chance to improve language difficulties and produce positive, long-term effects, with an increased likelihood for successful developmental and educational outcomes (Conti-Ramsden & Durkin, 2012).

Research has widely documented that children with language impairment who receive intervention during the toddler years have less likelihood of requiring special education when they reach school age (Wittke & Spaulding, 2018).

Best practices
According to Johnson, Beitchmen, and Brownlie (2009), teacher ratings are consistently better predictors of child behavior problems than parent ratings. It is mainly because teachers are able to make a better judgment of a child’s behavior in comparison with same-age peers.

However, Zhang and Tomblin (2000) further suggested that we should not depend only on teachers’ and parents’ observations and reports to identify language impairment, particularly because receptive (understanding others) language impairment is not readily detected by lay observation.

Conti-Ramsden and Durkin (2012) proposed that multi-method, multi-informant approaches are considered best practice. They suggest an evaluation of both expressive and receptive skills and more than one dimension of language.

Simms (2017) suggested “the gold standard of developmental diagnosis is evaluation by a multidisciplinary team of professionals who can observe a child in a variety of circumstances and develop a profile of strengths and deficits.” Furthermore, in an uncertain situation, a child should be given appropriate developmental and educational interventions before a clinical diagnosis is made by at least a medical professional.

Ideally, every young child who has delays, or may be at risk for language delays within the first three years of life, would have access to high quality early intervention services to increase developmental growth and minimize language impairment (Paul & Roth, 2011a).

Tips for teachers
You need not be concerned about a child who displays a random behavior once in a while. But if you observe and document recurring language issues, the following guidelines may be helpful.
Be familiar with developmental milestones. Your program may already have a developmental checklist, such as the one offered online by the National Institute on Deafness and Other Communication Disorders (www.nidcd.nih.gov/health/speech-and-language).

You can refer parents to the online link or give a printed handout. Throughout the first few years of a child’s development, it is important to offer this information to parents regularly. For infants and toddlers, the information sheet will cover every three to six months of their development, whereas an information sheet for older children will cover milestones by year. Young children go through many major changes within the first few years, so it is necessary to break down the information by age as well as by developmental domains.

If there is a question or concern that has been observed over a period of time in multiple settings, encourage parents to see a doctor or a specialist.
Maintain open communication with parents. In some states, compulsory education does not start until kindergarten or first grade. In such case, some toddlers and preschoolers can miss being identified until later. Early care and education teachers are in a better position to interact with children at a much younger age than formal schoolteachers. With this advantage, you are wise to give parents a brief report of what their child does every day, and, if necessary, specific concerns about language development.
Encourage annual physical checkups by a physician or other health professional. If something becomes questionable, encourage parents to ask for clarification.
If you have a concern about a child at any time, refer parents first to a pediatrician. A pediatrician will compare the child’s development to what is typical for the child’s age as well as consider the child’s medical history. The pediatrician may recommend having a child’s language skills screened and evaluated, if needed.

According to Gillam and Gillam (2006), it is vital to seek evidence-based practice professionals who are familiar with the current research findings and practices.
Remember that the earlier a language disorder is identified and treated, the better the prognosis for improvement and even progress (Guralnick, 2011; Paul & Roth, 2011b; Wittke & Spaulding, 2018) toward positive behavioral, social, and academic outcomes.

Early detection improves prognosis
Learning builds upon itself in a cumulative manner for young children. A slow start could mean difficulties with developing skills later on. Language issues in particular can be misunderstood as behavior problems.

The goal of early detection is to recognize and identify children with language issues, so they can receive early intervention and avoid negative effects, such as poor social-emotional well-being and decreased cognitive development.

References
American Speech-Language-Hearing Association (n.d. a). Language in brief. Retrieved from www.asha.org/practice-portal/clinical-topics/spoken-language-disorders/language-in--brief/.
American Speech-Language-Hearing Association (n.d. b). Speech and language disorders and diseases. Retrieved from www.asha.org/public/speech/disorders/.
American Speech-Language-Hearing Association (n.d. c). Preschool language disorders. Retrieved from www.asha.org/public/speech/disorders/Preschool-Language-Disorders/#signs.
Arias, G., & Friberg, J. (2017). Bilingual language assessment: Contemporary versus recommended practice in American schools. Language, Speech, and Hearing Services in Schools, 48, 1-15.
Berger, K. (2014). The developing person: Through the lifespan, 9th ed. New York: Worth.
Center for Parent Information and Resources. (2015). Speech and language impairment. Retrieved from www.parentcenterhub.org/speechlanguage/.
Conti-Ramsden, G., & Durkin, K. (2012). Language development and assessment in the preschool period. Neuropsychological Review, 22, 384-401.
Eisenberg, S. L. & Guo, L. U. (2013). Differentiating children with and without language impairment based on grammaticality. Language, Speech, and Hearing Services in Schools, 44, 20-31.
Gillam, S. L. & Gillam, R. B. (2006). Making evidence-based decisions about child language intervention in school. Language, Speech, and Hearing Services at Schools, 37, 304-315.
Johnson, A. (2017). How do children learn language? Texas Child Care Quarterly, 40(4). Retrieved from www.childcarequarterly.com/pdf/spring17_language.pdf.
Johnson, C. J., Beitchman, J. H., & Brownlie, E. B. (2010). Twenty-year follow-up of children with and without speech-language impairments: Family, educational, occupational, and quality of life outcomes. American Journal of Speech-Language Pathology, 19, 51-65.
Langham, B., & Hubig M. (2017). Deaf education: A primer. Texas Child Care Quarterly, 41(1). Retrieved from www.childcarequarterly.com/pdf/summer17_deaf.pdf.
National Institute on Deafness and Other Communication Disorders (March 6, 2017). Specific language impairment. Retrieved from https://www.nidcd.nih.gov/health/specific-language-impairment.
Paul, R., & Roth, F. P. (2011a). Characterizing and predicting outcomes of communication delays in infants and toddlers: Implications for clinical practices. Language, Speech, and Hearing Services in Schools, 42, 331-340.
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Simms, M. D. (2017). When autistic behavior suggests a disease other than classic autism. Pediatric Clinics of North America, 64(1), 127-138.
Skahan, S. M., Watson, M., & Lof, G. L. (2007). Speech-language pathologists assessment practices for children with suspected speech sound disorders: Results of a national survey. American Journal of Speech Language Pathology, 16, 246-259.
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Thiemann-Bourque, K. S., Brady, N. C., & Fleming, K. K. (2012). Symbolic play of preschoolers with severe communication impairments with autism and other developmental delays: More similarities than differences. Journal of Autism and Developmental Disorders, 42(5), 863-873.
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Zhang, X. Y., & Tomblin, J. B. (2000). The association of intervention receipt with speech-language profiles and social-demographic variables. American Journal of Speech-Language Pathology, 9, 345-357.

About the authors
Shann Hwa Hwang, Ph.D., CFLE, is a professor of Family Studies in the Department of Family Sciences at Texas Woman’s University in Denton, Texas. He is a Certified Family Life Educator. He teaches classes on family development, diversity, parenting education, research methods, and family theories. His research focuses on father-child relationships, financial stress, couple conflict, and Asian immigrant families.

Wendy K. Lee, M.S, is vice president of Internal Affairs of Bethel Hearing and Speaking Training Center. She is a member of the American Speech-Language and Hearing Association. Ms. Lee has worked as a speech-language pathologist in the acute care, inpatient rehabilitation, outpatient, and home health rehabilitation settings.

Isaiah M. Hwang is an advanced placement scholar and has been a research intern for Bethel Hearing and Speaking Training Center for over 2 years. He completed AP Research and AP Statistics and is currently a senior at Independence High School.