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

315.32 Mixed Receptive-Expressive Language Disorder

Diagnostic Features

The essential feature of Mixed Receptive-Expressive Language Disorder is an impairment in both receptive and expressive language development as demonstrated by scores on standardized individually administered measures of both receptive and expressive language development that are substantially below those obtained from standardized measures of nonverbal intellectual capacity (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), and the symptoms do not meet criteria for 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 a neurological condition is present, it should be coded on Axis III.

An individual with this disorder has the difficulties associated with Expressive Language Disorder (e.g., a markedly limited vocabulary, errors in tense, difficulty recalling words or producing sentences with developmentally appropriate length or complexity, and general difficulty expressing ideas) and also has impairment in receptive language development (e.g., difficulty understanding words, sentences, or specific types of words). In mild cases, there may be difficulties only in understanding particular types of words (e.g., spatial terms) or statements (e.g., complex "if-then" sentences). In more severe cases, there may be multiple disabilities, including an inability to understand basic vocabulary or simple sentences, and deficits in various areas of auditory processing (e.g., discrimination of sounds, association of sounds and symbols, storage, recall, and sequencing). Because the development of expressive language in childhood relies on the acquisition of receptive skills, a pure receptive language disorder (analogous to a Wernicke's aphasia in adults) is virtually never seen (although in some cases the receptive deficit may be more severe than the expressive one).

Mixed Receptive-Expressive Language Disorder may be either acquired or developmental. In the acquired type, an impairment in receptive and 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 receptive and expressive language that is not associated with a neurological insult of known origin. This type is characterized by a slow rate of language development in which speech may begin late and advance slowly through the stages of language development.

Associated Features and Disorders

The linguistic features of the production impairment in Mixed Receptive-Expressive Language Disorder are similar to those that accompany Expressive Language Disorder. The comprehension deficit is the primary feature that differentiates this disorder from Expressive Language Disorder, and this can vary depending on the severity of the disorder and the age of the child. Impairments in language comprehension can be less obvious than those in language production because they are not as readily apparent to the observer and may appear only on formal assessment. The child may intermittently appear not to hear or to be confused or not paying attention when spoken to. The child may follow commands incorrectly, or not at all, and give tangential or inappropriate responses to questions. The child may be exceptionally quiet or, conversely, very talkative. Conversational skills (e.g., taking turns, maintaining a topic) are often quite poor or inappropriate. Deficits in various areas of sensory information processing are common, especially in temporal auditory processing (e.g., processing rate, association of sounds and symbols, sequence of sounds and memory, attention to and discrimination of sounds); these kinds of difficulties are sometimes referred to as "central auditory processing" disorders.

Difficulty in producing motor sequences smoothly and quickly is also characteristic. Phonological Disorder, Learning Disorders, and deficits in speech perception are often present and accompanied by memory impairments. Other associated disorders are Attention-Deficit/Hyperactivity Disorder, Developmental Coordination Disorder, and Enuresis. Mixed Receptive-Expressive Language Disorder may be accompanied by EEG abnormalities, abnormal findings on neuroimaging, and other neurological signs. A form of acquired Mixed Receptive-Expressive Language Disorder that has its onset at about ages 3-9 years and is accompanied by seizures is referred to as Landau-Kleffner syndrome.

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. The developmental type is probably more prevalent in males than in females.

Prevalence

Prevalence estimates vary with age. It is estimated that the developmental type of Mixed Receptive-Expressive Language Disorder may occur in up to 5% of preschool children and 3% of school-age children but is probably less common than Expressive Language Disorder. Landau-Kleffner syndrome and other forms of the acquired type of the disorder are relatively uncommon.

Course

The developmental type of Mixed Receptive-Expressive Language Disorder is usually detectable before age 4 years. Severe forms of the disorder may be apparent by age 2 years. Milder forms may not be recognized until the child reaches elementary school, where deficits in comprehension become more apparent. The acquired type of Mixed Receptive-Expressive Language Disorder due to brain lesions, head trauma, or stroke may occur at any age. The acquired type due to Landau-Kleffner syndrome (acquired epileptic aphasia) usually occurs between ages 3 and 9 years. Many children with Mixed Receptive-Expressive Language Disorder eventually acquire normal language abilities, but the prognosis is worse than for those with Expressive Language Disorder. In the acquired type of Mixed Receptive-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 complete or nearly so. In other instances, there may be incomplete recovery or progressive deficit. Children with more severe forms are likely to develop Learning Disorders.

Familial Pattern

The developmental type of Mixed Receptive-Expressive Language Disorder is more common among first-degree biological relatives of those with the disorder than in the general population. There is no evidence of familial aggregation in the acquired type of the disorder.

Differential Diagnosis

See the "Differential Diagnosis" section for Expressive Language Disorder (p. 60).

Diagnostic criteria for 315.32 Mixed Receptive-Expressive Language Disorder

1. The scores obtained from a battery of standardized individually administered measures of both receptive and expressive language development are substantially below those obtained from standardized measures of nonverbal intellectual capacity. Symptoms include those for Expressive Language Disorder as well as difficulty understanding words, sentences, or specific types of words, such as spatial terms.
2. The difficulties with receptive and expressive language significantly interfere with academic or occupational achievement or with social communication.
3. Criteria are not met for 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.