The risk of social-emotional deficits in language-impaired young children

In recent years there has been an increase in infants, toddlers and preschoolers diagnosed with significant social-emotional and/or behavioral problems.  An estimated 10% to 15% of birth-5 year-old population experience serious social-emotional problems which significantly impact their functioning and development in the areas of language, behavior, cognition and school-readiness (Brauner & Stephens, 2006).

However, some studies have found that many parents have limited knowledge about mental health issues in young children (Alexander, Brijnath, & Mazza, 2013; Rescorla, Ross & McLure 2007).  Factors impacting parental recognition of mental health difficulties in their children may include: doubts about early age of onset (many parents believe that children will grow out of inappropriate behaviors), recommendations to ‘wait and see’ by pediatricians, friends and relatives, lack of awareness of severity of problematic behaviors (‘it’s not that bad’), as well as unintentional lack of recognition of presenting behaviors (e.g, labeling evident anxiety as ‘a bit shy”).

As a result, early identification of and service provision to infants, toddlers, and preschoolers  with social-emotional/behavioral deficits continues to be fraught with significant difficulties. For example, one study has found that less than 8% of 1- and 2-year olds with social-emotional/behavioral problems tend to receive any developmental or mental health services (Horwitz, Gary, Briggs-Gowan, & Carter, 2003).  Furthermore, young children with emotional behavioral disturbances (EBD) tend to receive services that focus on developmental issues, such as speech/language, gross/fine motor, and cognitive delays vs. mental health (psychotherapy) (Briggs-Gowan, et al 2004). But what if the psycho-therapeutic intervention is required in addition to the provided developmental interventions?

This places Early Intervention (EI) and preschool based providers, including, speech language pathologists, in a unique position. They are one of the first professionals who have the potential to recognize the presence of social behavioral difficulties in language impaired birth-preschool population and make a relevant service referral. This may be needed due to a strong connection between speech-language impairments and behavioral disorders (Baker & Cantwell, 1987; Benner, Nelson, & Epstein, 2002). Children with childhood language impairment are more likely to experience both concurrent and future behavioral problems than typically developing children (Conti-Ramsden & Botting, 2008; Snowling, et al, 2006).

So how can we recognize if a child is exhibiting emotional behavioral deficits or is simply acting out (e.g, ‘terrible twos’)?

For starters we need to consider a number of variables since not every child with language impairment and/or behavioral difficulties will have a true psychiatric impairment.

Let’s begin with children with suspected or diagnosed with language disorders and delays who display maladaptive behaviors (e.g., severe aggression, anxiety, withdrawal, etc).  The first question of course should be: Are the behaviors due to a language impairment? Is the child acting out due to an inability to have his/her needs met? In other words, once the child receives speech language services, which improve his/her language abilities, will the behaviors lessen in intensity or disappear all together?

To find out, SLPs can begin by administering a comprehensive speech language assessment to determine the child’s linguistic status and social pragmatic competence.  They need to gather careful social history. Then administer formal and informal testing which includes a language sample, play skills assessment, narrative assessment, as well as behavioral and social pragmatic questionnaires.  If the assessment yields that therapy is warranted it is important to carefully track progress as intervention is administered to see if the behavioral manifestations are improving along with the the language abilities. On many occasions the improvement of language will trigger the reduction or disappearance of maladaptive behaviors. However, on other occasions you may see children making steady language gains in therapy yet their behavior will continue to present a serious cause for concern. Or you may see lack of progress in both areas, language and behavior, despite intensive intervention.

In such cases we need to consider additional variables:

First there’s the question of behavior duration. Has adequate time passed since the initiation of language intervention or is more time/gains needed? Then there’s the questions of —behavior intensity. Are the behaviors very severe? Do they last a short while and a child is relatively easy to soothe or do they last for an extended period of time and interfere with learning (child doesn’t participate in sessions; child learns very little despite intensive intervention due to maladaptive behaviors). Finally, is there a persistent continuation of significantly immature age-inappropriate behaviors despite consistent and productive therapy provision?