DSM-IV-TR › Disorders usually first diagnosed in infancy, childhood, or adolescence › Communication disorders › Expressive language disorder 

315.31 Expressive Language Disorder

Diagnostic Features

The essential feature of Expressive Language Disorder is an impairment in expressive language development as demonstrated by scores on standardized individually administered measures of expressive language development substantially below those obtained from standardized measures of both nonverbal intellectual capacity and receptive language development (Criterion A). When standardized instruments are not available or appropriate, the diagnosis may be based on a thorough functional assessment of the individual's language ability. The difficulties may occur in communication involving both verbal language and sign language. The language difficulties interfere with academic or occupational achievement or with social communication (Criterion B). The symptoms do not meet criteria for Mixed Receptive-Expressive Language Disorder or a Pervasive Developmental Disorder (Criterion C). If Mental Retardation, a speech-motor or sensory deficit, or environmental deprivation is present, the language difficulties are in excess of those usually associated with these problems (Criterion D). If a speech-motor or sensory deficit or neurological condition is present, it should be coded on Axis III.

The linguistic features of the disorder vary depending on its severity and the age of the child. These features include a limited amount of speech, limited range of vocabulary, difficulty acquiring new words, word-finding or vocabulary errors, shortened sentences, simplified grammatical structures, limited varieties of grammatical structures (e.g., verb forms), limited varieties of sentence types (e.g., imperatives, questions), omissions of critical parts of sentences, use of unusual word order, and slow rate of language development. Nonlinguistic functioning (as measured by performance intelligence tests) and language comprehension skills are usually within normal limits. Expressive Language Disorder may be either acquired or developmental. In the acquired type, an impairment in expressive language occurs after a period of normal development as a result of a neurological or other general medical condition (e.g., encephalitis, head trauma, irradiation). In the developmental type, there is an impairment in expressive language that is not associated with a postnatal neurological insult of known origin. Children with this type often begin speaking late and progress more slowly than usual through the various stages of expressive language development.

Associated Features and Disorders

The most common associated feature of Expressive Language Disorder in younger children is Phonological Disorder. There may also be a disturbance in fluency and language formulation involving an abnormally rapid rate and erratic rhythm of speech and disturbances in language structure ("cluttering"). When Expressive Language Disorder is acquired, additional speech difficulties are also common and may include motor articulation problems, phonological errors, slow speech, syllable repetitions, and monotonous intonation and stress patterns. Among school-age children, school and learning problems (e.g., writing to dictation, copying sentences, and spelling) that sometimes meet criteria for Learning Disorders are often associated with Expressive Language Disorder. There may also be some mild impairment in receptive language skills, but when this is significant, a diagnosis of Mixed Receptive-Expressive Language Disorder should be made. A history of delay in reaching some motor milestones, Developmental Coordination Disorder, and Enuresis are not uncommon. Social withdrawal and some mental disorders such as Attention-Deficit/Hyperactivity Disorder are also commonly associated. Expressive Language Disorder may be accompanied by EEG abnormalities, abnormal findings on neuroimaging, dysarthric or apraxic behaviors, or other neurological signs.

Specific Culture and Gender Features

Assessments of the development of communication abilities must take into account the individual's cultural and language context, particularly for individuals growing up in bilingual environments. The standardized measures of language development and of nonverbal intellectual capacity must be relevant for the cultural and linguistic group (i.e., tests developed and standardized for one group may not provide appropriate norms for a different group). The developmental type of Expressive Language Disorder is more common in males than in females.

Prevalence

Prevalence estimates vary with age. In children under 3, language delays are quite common, occurring in 10%-15% of children. By school age, prevalence estimates range from 3% to 7%. The developmental type of Expressive Language Disorder is more common than the acquired type.

Course

The developmental type of Expressive Language Disorder is usually recognized by age 3 years, although milder forms of the disorder may not become apparent until early adolescence, when language ordinarily becomes more complex. The acquired type of Expressive Language Disorder due to brain lesions, head trauma, or stroke may occur at any age, and the onset is sudden. The outcome of the developmental type of Expressive Language Disorder is variable. A majority of children with this disorder improve substantially; in a smaller proportion, difficulties persist into adulthood.

Most children ultimately acquire more or less normal language abilities by late adolescence, although subtle deficits may persist. In the acquired type of Expressive Language Disorder, the course and prognosis are related to the severity and location of brain pathology, as well as to the age of the child and the extent of language development at the time the disorder is acquired. Clinical improvement in language abilities is sometimes rapid and complete, although deficits in communication and related cognitive abilities may persist. In other instances there may be progressive deficit.

Familial Pattern

It appears that the developmental type of Expressive Language Disorder is more likely to occur in individuals who have a family history of Communication or Learning Disorders. There is no evidence of familial aggregation in the acquired type.

Differential Diagnosis

Expressive Language Disorder is distinguished from Mixed Receptive-Expressive Language Disorder by the presence in the latter of significant impairment in receptive language; many individuals with Expressive Language Disorder have subtle difficulties in receptive skills as well.

Expressive Language Disorder is not diagnosed if the criteria are met for Autistic Disorder or another Pervasive Developmental Disorder. Autistic Disorder also involves expressive language impairment but may be distinguished from Expressive and Mixed Receptive-Expressive Language Disorders by the characteristics of the communication impairment (e.g., stereotyped use of language) and by the presence of a qualitative impairment in social interaction and restricted, repetitive, and stereotyped patterns of behavior. Expressive and receptive language development may be impaired due to Mental Retardation, a hearing impairment or other sensory deficit, a speech-motor deficit, or severe environmental deprivation. The presence of these problems may be established by intelligence testing, audiometric testing, neurological testing, and history. If the language difficulties are in excess of those usually associated with these problems, a concurrent diagnosis of Expressive Language or Mixed Receptive-Expressive Language Disorder may be made. Children with expressive language delays due to environmental deprivation may show rapid gains once the environmental problems are ameliorated.

In Disorder of Written Expression, there is a disturbance in writing skills. If deficits in oral expression are also present, an additional diagnosis of Expressive Language Disorder may be appropriate. Selective Mutism involves limited expressive output that may mimic Expressive or Mixed Receptive-Expressive Language Disorder; careful history and observation are necessary to determine the presence of normal language in some settings. Acquired aphasia associated with a general medical condition in childhood is often transient. A diagnosis of Expressive Language Disorder is appropriate only if the language disturbance persists beyond the acute recovery period for the etiological general medical condition (e.g., head trauma, viral infection).

Diagnostic criteria for 315.31 Expressive Language Disorder

1. The scores obtained from standardized individually administered measures of expressive language development are substantially below those obtained from standardized measures of both nonverbal intellectual capacity and receptive language development. The disturbance may be manifest clinically by symptoms that include having a markedly limited vocabulary, making errors in tense, or having difficulty recalling words or producing sentences with developmentally appropriate length or complexity.
2. The difficulties with expressive language interfere with academic or occupational achievement or with social communication.
3. Criteria are not met for Mixed Receptive-Expressive Language Disorder or a Pervasive Developmental Disorder.
4. If Mental Retardation, a speech-motor or sensory deficit, or environmental deprivation is present, the language difficulties are in excess of those usually associated with these problems.

Coding note: If a speech-motor or sensory deficit or a neurological condition is present, code the condition on Axis III.

Reprinted with permission from the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision^TM. Copyright 2000 American Psychiatric Association. All Rights Reserved.