Journal of Speech and Hearing Disorders,Volume 55, 179-192, May 1990

COMMUNICATION DISORDERS AND EMOTIONAL/BEHAVIORAL DISORDERS IN CHILDREN AND ADOLESCENTS BARRY M. PRIZANT Brown University Program in Medicine Providence, RI and Bradley Hospital East Providence, RI LISA R. AUDET

GRACE M. BURKE LAUREN J. HUMMEL GERALDINE THEADORE Bradley Hospital East Providence, RI

SUZANNE R. MAHER

Recent research in child psychiatry has demonstrated a high prevalence of speech, language, and communication disorders in children referred to psychiatric and mental health settings for emotional and behavioral problems. Conversely, children referred to speech and language clinics for communication disorders have been found to have a high rate of diagnosable psychiatric disorders. Most of the emerging knowledge regarding relationships between communication disorders and psychiatric disorders has been presented in the child psychiatric literature. Speech-language pathologists and audiologists also need to be familiar with this information; an understanding of the complex interrelationships between communication disorders and emotional and behavioral disorders is important for diagnosis, assessment, and treatment. The purpose of this article is to review recent research and discuss clinical implications for professionals in speech-language pathology and audiology working with children and adolescents who have, or who are at risk for, developing emotional and behavioral disorders. Issues to be addressed include differential diagnosis, prevention, intervention, and the role of speech-language pathologists serving these children and adolescents. KEY WORDS: emotional disorders, behavioral disorders, communication disorders, psychiatric disorders, speech-language pathologists

THEORETICAL

The nature of this relationship has been discussed in publications of the American Speech-Language-Hearing Association as early as the 1950s when McCarthy (1954) suggested that certain personality traits are associated

ISSUES

The Relationship Between Communication Disorders and PsychiatricDisorders

with language disorders in children. Trapp and Evan (1960) noted that children with articulation disorders have anxiety levels that correspond with the level of severity of their articulation disorder. Waller, Sollod, Sander and Kunicki (1983) stated, "Interest in a relation between functional speech/language disorders and psychopathology is hardly new to our profession" (p. 94). However, this interest historically has taken the form of theories as to the cause/effect relationship between psy-

Recent research has demonstrated that there is a relationship between communication disorders, emotional disorders, and behavioral disorders in children and adolescents (Baker & Cantwell, 1987a; Gualtieri, Koriath, Van Bourgondien, & Saleeby, 1983). Following a compre-

hensive literature review, Baker and Cantwell (1987b)

chological dynamics or personality and speech, fluency, articulation, and language disorders. Furthermore, earlier

concluded that "the literature strongly suggests that children with delays or disorders of development in speech or language are 'at risk' for both psychiatric and learning disorders" (p. 546). Most speech-language pathologists who work with children and adolescents with communication disorders have been challenged by the behavioral and emotional difficulties experienced by some of their clients. Baker and Cantwell (1982a), a child psychiatrist and developmental psycholinguist respectively, noted,

accounts often were derived from clinical experience or were based on case studies, and there was considerably less emphasis on relationships between communication disorders and emotional/behavioral disorders. In recent years, there has been a renewed interest and reemphasis on these relationships, resulting in an emerging body of research and clinical literature. This newer information supports the need for speech-language pathologists to keep this relationship in mind when approaching the diagnosis and treatment of speech-language-impaired children. Thus, speech-language pathologists need to become familiar with this literature and the issues generated by this renewed interest.

Conferences with speech pathologists will elicit the uniform opinion that the patients that they are seeing in their practices are frequently emotionally disturbed. But such clinicians will be unable to quantify how many, how seriously, or more important, which of the children they see are so affected. (p. 291) © 1990, American Speech-Language-Hearing Association

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0022-4677/90/5502-0179$01.00/0

180 Journal of Speech and HearingDisorders Recently, researchers in speech-language pathology have begun to explore these issues by studying topics such as types of communication disorders in child psychiatric populations (Baltaxe & Simmons, 1988a, 1988b), self-concept in communicatively disordered children (Brandell & Wirhanowicz, 1985), language disorders in children with mild/moderate behavioral disorders (Camarata, Hughes, & Ruhl, 1988) communication disorders in abused and neglected children (Bloom & Collins, 1987), and language and speech disorders in an inpatient psychiatric setting (Burks, 1987). These studies have documented a high prevalence rate of co-occurrence of communication disorders and emotional/behavioral disorders in children and adolescents. Rates of co-occurrence vary according to the specific settings and subjects in these studies. Researchers have discussed the potential consequences of communication disorders in children. Baker and Cantwell (1983) noted that since language is a uniquely human quality, it is therefore not unexpected that a disorder in language development might have far reaching consequences for other areas of early childhood development. In fact, systematic research has suggested that language is uniquely and intrinsically related to the development of the child's thought, play activities, social and emotional development and learning. (p. 51-52)

An understanding of the relationship between communication disorders, emotional disorders, and behavioral disorders in children and adolescents is critical if the needs of the children served by speech-language pathologists are to be met.

Diagnosis of PsychiatricDisorders Baker and Cantwell (1987a) provided the following working definition of psychiatric disorder: "a disorder of behavior, emotions or relationships that is sufficiently severe and/or sufficiently prolonged, to cause disturbance in the child or disruption of his immediate environment" (p. 193). Adult and childhood psychiatric disorders currently are diagnosed according to DSM III-R (1987), a taxonomy that has its origins in a classification system originally adopted in 1889. The Diagnosticand Statistical Manual of Mental Disorders-I (1951) was revised and updated with three subsequent versions: DSM 11 (1968), DSM III1 (1980), and the current classification system, DSM III-R (1987). When reviewing psychiatric literature, it is important to be cognizant of the various taxonomies that have been used over the years, for diagnostic categories and criteria for diagnosis have changed considerably. The current DSM III-R (1987) multiaxial system consists of five axes (see Table 1). Axis I includes clinical syndromes. A clinical syndrome must have as essential features "a group of symptoms that occur together and constitute a recognizable condition" (DSM III-R, 1987, p. 405). For example, Attention-Deficit Hyperactivity Disorder (ADHD), a subcategory of Disruptive Behavior Disorders, is defined by "developmentally inappropriate degrees

55 179-192 TABLE

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1. DSM III-R multiaxial system (APA, 1987).

Axis I Axis II Axis III Axis IV Axis V

Clinical syndromes V Codes Developmental disorders Personality disorders Physical disorders and conditions Severity of psychosocial stressors Global assessment of functioning

of inattention, impulsiveness and hyperactivity" (DSM III-R, 1987, p. 50). Other examples of categories of Axis I disorders are Schizophrenia, Mood Disorders, and Anxiety Disorders. Also included under Axis I are V Codes. V Codes are problems not attributed to a mental disorder, but are the

focus of attention or treatment. Examples of V Codes include academic problems not necessarily related to specific skill deficits, mother-child relationship problems, or sexual/ physical abuse. Axis II includes Developmental Disorders with subcategories of Mental Retardation, Specific Developmental Disorders, and Pervasive Developmental Disorders. Axis II also includes Personality Disorders. All of these Axis II diagnostic categories reflect patterns of behavior that are long standing and not easily resolvable. Examples of Specific Developmental Disorders include Developmental Receptive and Expressive Language Disorders, Developmental Articulation Disorder, Developmental Reading Disorder, Developmental Expressive Writing Disorder, Developmental Arithmetic Disorder, and Developmental Coordination Disorder. Pervasive Developmental Disorders include Autistic Disorder and Pervasive Developmental Disorder NOS (not otherwise specified). Personality Disorders include categories such as Paranoid, AntiSocial, and others. Axis III includes physical disorders and medical conditions such as sensorineural hearing loss or cerebral palsy. Axis IV is a continuum rating of severity of psychosocial stressors (i.e., none, mild, moderate, severe, extreme, catastrophic). Psychosocial stressors include a variety of events that happen within an individual's environment that cause distress and require adaptation. Expulsion from school, the birth of a sibling, and sexual/ physical abuse are examples of psychosocial stress. Axis V, Global Assessment of Functioning, is a rating of mental health that takes into consideration the psychological, social, and occupational functioning of the individual. A rating is made on a scale of 1-90 with 1 being persistent dangerof severely hurting self or others andlor inability to maintain minimal personal hygiene, and 90 being absence of symptoms. Baltaxe and Simmons (1988a) presented a breakdown of seven ways, which are not necessarily mutually exclusive, that communication handicaps can occur within the DSM III (APA, 1980) framework: 1. The communication handicap may constitute the sole mental disorder. This is the case in the diagnosis of developmental language disorder, stuttering, and elective mutism.

2. The communication handicap may co-occur with another mental disorder without obvious ties to that

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PRIZANT ET AL.: EmotionallBehavioralDisorders disorder. This is the case when a communication handicap also occurs in the presence of another psychiatric diagnosis, such as conduct disorder or anxiety disorder. 3. The communication handicap may be part of the essential criteria for the diagnosis of a specific mental disorder. This is the case in the diagnosis of infantile autism and pervasive developmental disorder, where language deficits are specifically listed as essential diagnostic criteria. 4. The communication handicap may constitute an associated characteristic in the diagnosis of a mental disorder. For example, a communication handicap in the form of a developmental delay is presumed to be present in the diagnosis of mental retardation. There, the developmental language lag may represent an aspect of the overall level of cognitive functioning. The language handicap in this case is not specifically listed among the diagnostic criteria. 5. Underlying processing difficulties commonly associated with communication handicaps may also constitute characteristics of the psychiatric diagnosis. For example, auditory processing difficulties are commonly associated with communication deficits. They are also associated with the psychiatric diagnosis of attention deficit disorder. 6. Communication handicaps may constitute essential characteristics in the diagnosis of a thought disorder in cases of psychosis and schizophrenia. In this example, specific pragmatic deficits involving speaker-hearer relations are present. 7. Prolonged communication failure may lead to secondary psychiatric problems.' As is apparent, in the DSM III (1980) and DSM III-R (APA, 1987) classification systems, many psychiatric disorders have speech and language symptomatology specific to the overall diagnosis. As will be discussed later, this poses a challenge to differential diagnosis between communication disorders and psychiatric disorders. Research on the Relationship Between Communication and Emotional/Behavioral Disorders Researchers in child psychiatry have established an empirical base substantiating the relationship between communication disorders and psychiatric disorders (Baker & Cantwell, 1982b, 1987b; Beitchman, Nair, Clegg, Ferguson, & Patel, 1986; Cantwell, Baker, & Mattison, 1979, 1981; Gualtieri et al., 1983). Gualtieri et al. (1983) surveyed 40 consecutive admissions to a child psychiatric inpatient facility. They found-after in depth speech, language, and intelligence testing-that 20 of the 40 admissions had moderate to severe language disorders. They then concluded that "there appears to be a strong association between developmental language deficits and severe psychiatric disorders" (p. 168). They added that "disorders of the development of language are likely to be central to the development of human personality.

'From Seminars in Speech and Language, 8, by C. Baltaxe and J. Simmons, 1988, New York: Thieme Medical Publishers. Copyright 1988 by Thieme Medical Publishers. Reprinted by permission.

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Understanding and correcting deficiencies of language can improve behavior and help a child resolve at least some of his emotional dilemmas" (p. 169). Baker and Cantwell (1982b) studied the prevalence of psychiatric impairment in speech- and languageimpaired children seen at a community-based speech clinic (age range: 1 year 11 months-15 years 11 months). Of the first 291 children studied, 44% had some psychiatric illness according to criteria in the Diagnostic and Statistical Manual of Mental Disorders-ThirdEdition (APA 1980). They found that children presenting with a "pure language disorder" (n = 19) of language expression, comprehension, or processing, but with speech being normal, were the most seriously at risk for the development of psychiatric disorders (95% prevalence rate) and had the highest mean age (M = 9.3 years; SD = 3.4). The prevalence rates of psychiatric illness and mean ages for the "pure speech disordered" (n = 108) was 29% and 6.0 years (SD = 2.6), respectively, and for the "speech-and-language-disordered" group (n = 164), 45% and 4.9 years (SD = 2.3). A follow-up study of the same sample (Baker & Cantwell, 1987b) revealed that the overall prevalence rate of psychiatric disorders in the total sample of speech- and language-disordered children had increased from 44% to 60%. Diagnosis of Attention Deficit Disorder (ADD) and Anxiety Disorder had doubled. Over the 5-year period, some children who previously had been diagnosed "psychiatrically well" developed psychiatric disorders including Dysthymic Disorder, Separation Anxiety Disorder, Oppositional Disorder, Adjustment Disorder, and Avoidant Disorder. It should be noted that some of these disorders typically have a later onset in terms of their natural history. Beitchman, Nair, Clegg, and Patel (1986) conducted an epidemiological study of 1,655 five-year-old kindergarten children in Canada who were assessed for speech and language disorders. They found 11% had speech and language disorders and, of these, 48.7% presented with a psychiatric disorder as well as a speech and language disorder. In England, Stevenson and Richman (1976) found that 59% of 3-year-old children with expressive language delays had behavioral disturbances. Finally, in an ongoing study in our setting, 38 of 55 consecutive admissions (67%) to a children's inpatient unit failed a speech and language screening upon admission. It is important to note that none of these children had significant cognitive deficits or pervasive developmental disorders. Thus, a high rate of co-occurrence of speech-language disorders and emotional and behavioral disorders in children and adolescents has been documented in numerous studies in at least three countries. Baltaxe and Simmons (1988a) published a literature review of studies of pragmatic deficits in emotionally disturbed children and adolescents with communication disorders and noted that the "domain of emotional disorders has only begun to be explored with respect to identifying pragmatic disorders" (p. 242). Literature regarding children with psychiatric disorders, behavioral disorders, mental disorders, and psychopathology was reviewed, and seven case studies were presented. Pragmatic deficits

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182 Journal of Speech and Hearing Disorders noted by the authors included nonlinguistic as well as linguistic behaviors. These authors suggested that when pragmatic development is viewed as the interface of four, rather than three, principal developmental dimensions (i.e., linguistic, social, cognitive, and affective), it may also be argued that children who suffer from lags, deficits, or disorders in emotional development may be at risk for pragmatic deficits. (p. 226) The association between juvenile delinquency and learning disabilities also has been a focus of research (Lane, 1980; Wilgosh & Paitich, 1982). The significant relationship between language disorders and learning disabilities has been discussed elsewhere (Maxwell & Wallach, 1984). Thus, it is likely that these research studies include a significant proportion of language/learningdisabled subjects. Meltzer, Roditi, and Fenton (1986) suggested that various subtypes of delinquency could be differentiated. One of these subtypes is unique to delinquency and possibly reflects a group of children's behavioral and social problems superimposed on specific learning profiles. A second subtype displayed cognitive and educational profiles virtually identical to the profiles of learning-disabled adolescents. A third subgroup was characterized by learning and cognitive profiles similar to those of average achievers. The authors concluded that their results "suggest that juvenile delinquency may represent one possible end result of a specific learning disability" (p. 589). They postulated that in some children "learning problems and behavioral disorders may occur simultaneously; in others, common factors may contribute to both learning disabilities and juvenile delinquency and ... learning problems may often lead to school failure and low self esteem" (pp. 589-590). They further developed this model to state that the negative self-image can contribute to the development of juvenile delinquency. Clearly, speech-language pathologists need to become familiar with the relationship between communication disorders and psychiatric disorders because a significant proportion of their clients/patients are likely to experience both. As will be discussed, knowledge of this relationship may have a direct influence on differential diagnosis, contexts and content of treatment, and service delivery and educational placement considerations. Types of PsychiatricDisorders in Communicatively DisorderedChildren and Adolescents Researchers have only recently addressed issues of the types of psychiatric disorders found in communicatively disordered children and adolescents. Some types of psychiatric disorders have been found to occur more often in the speech- and language-impaired population. Baker and Cantwell (1987a) identified two major groupings of psychiatric disorders in DSM III (APA, 1980) as being strongly associated with communication disorders: behavior disorders and emotional disorders. These are differentiated on the basis of behavioral symptoms. Chil-

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dren and adolescents with behavior disorders frequently exhibit overt behaviors (e.g., overactivity, aggression) that disturb the environment and people nearby. This category includes Attention Deficit Hyperactivity Disorder (ADHD), Oppositional Disorder, and Conduct Disorder. Children and adolescents with emotional disorders may experience internalized and/or somatic symptoms that do not directly disrupt the environment. This category includes Anxiety Disorders, phobias, and forms of depression. Diagnoses of emotional disorders and behavioral disorders are not necessarily mutually exclusive. Beitchman, Nair, Clegg, Ferguson, and Patel (1986), using a slightly different breakdown, found that two of three psychiatric disorders (i.e., Emotional Disturbance, Attention Deficit Disorder) were far more prevalent in speech- and language-impaired kindergarten children than in the non-speech-language-impaired control group. [Beitchman et al.'s category of' Emotional Disturbance included DSM III (APA, 1980) diagnoses of Avoidant Disorder and Adjustment Disorder. The reader is referred to DSM III-R (APA, 1987) for updated definitions and diagnostic criteria of these psychiatric diagnoses.] Table 2 presents these comparisons. Cantwell and Baker (1985) found that certain types of' communication disorders were associated more often with psychiatric disorders in their speech and language clinic sample. For example, disorders of language expression, comprehension, and processing were found to be associated more often with psychiatric illness than speech disorders alone. Factors that distinguished the psychiatrically ill speech- and language-impaired children from the psychiatrically well speech- and language-impaired children included a greater proportion of boys, and an increased incidence of psychosocial stressors and non-language developmental disorders (Baker & Cantwell, 1987a). When Baker and Cantwell (1987b) reviewed their complete findings in their 5-year follow-up study of their speech and language clinic sample, they found that 95% of the children had received speech and language remediation. Speech and language intervention alone, however, was not found to prevent later development of learning or psychiatric disorders nor did it ameliorate the learning disorders and/or psychiatric disorders in children who had them initially. However, Baker and Cantwell (1987b) measured only the presence or absence of emotional/behavioral symptoms at follow-up, and not improvement in frequency or severity of symptoms. Thus, possible positive effects of' speech and language intervention on emotional/behavioral 2. Percentage of different types of psychiatric disorders in speech- and language-impaired children in kindergarten and control children (Beitchman, Nair, Clegg, Ferguson, & Patel, TABLE

1986).

Psychiatricdisorder Emotionally disturbed Attention deficit disorder Conduct disorder

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Speech and language Control group (n = 137) impaired(n = 135) 12.8 30.4 5.5

1.5 4.5 6.0

PRIZANT ET AL.:

functioning cannot be ruled out. Substantial improvement was noted in communication skills. Hypothetical Models of Causality There is sufficient evidence from research and clinical practice that a relationship exists between communication disorders and emotional/behavioral disorders; however, the nature of this relationship remains unclear. At least four hypothetical models dealing with the question of direction of causality are suggested in the literature and/or from our clinical practice. The first hypothetical model stipulates that psychiatric disorders lead to communication disorders. There is, however, little empirical evidence to support this model. Based on our clinical practice, questions frequently are posed concerning the progression of specific psychiatric disorders as they relate to language development. For example, a child diagnosed with Attention-Deficit Hyperactivity Disorder (ADHD) may demonstrate difficulties in maintaining sustained attention to a task with language input presented auditorily. It is conceivable that the presence of these difficulties as language is developing may lead to receptive language and language-processing deficits. A second example is that of a child diagnosed with Dysthymic Disorder, a form of depression. The presence of mood disorders in young children, specifically depression, remains a controversial subject (Rutter, Izard, & Read, 1986). However, in our experience, young children diagnosed with Dysthymic Disorder often have limited social and verbal interactions. The decreased amount of social and verbal exchange could limit a child's language and social experiences during the early stages of language development, which conceivably could lead to speech and language delays and/or pragmatic deficits. The second hypothetical model stipulates that communication disorders lead to psychiatric disorders (Baltaxe & Simmons, 1988a). This hypothesis is based on the premise that communication difficulties lead to a variety of psychosocial deficits that may be mechanisms for the development of psychiatric disorders. Cantwell and Baker (1980) stated, "It is a likely hypothesis that a handicap in the development of speech and language would predispose children to the development of psychiatric problems, since language is considered to be one of the main features that makes us human" (p. 162). For example, children with a diagnosis of elective mutism, which is classified as a psychiatric disorder in DSM III-R, often have histories of speech and language problems. Wilkins (1985) compared case notes of 24 children diagnosed as electively mute to 24 children diagnosed with other emotional disorders. One third of the electively mute children had experienced delayed development of speech, but none of the matched controls had experienced such delays. Thus, it is conceivable that delays in speech and language development may be a major factor in the development of elective mutism for many children. Baker and Cantwell (1982b) found that almost half of the speech- and language-impaired children first referred

EmotionallBehavioralDisorders 183

to a community speech and language clinic had some psychiatric illness according to DSM III criteria. As noted, they found that children presenting with a disorder of language comprehension or processing were most seriously at risk for the development of psychiatric disorders, although specific psychiatric disorders were not clearly associated with specific types of language deficits. Many children and adolescents referred to psychiatric facilities have expressive language disorders (Gualtieri et al., 1983) that make it difficult for them to fully express their ideas, feelings, fears, and needs. Based on our experience, this group is representative of at least some children served by most speech-language pathologists both within and outside of mental health settings. These children may appear to be immature and restless, and may develop impulsive and aggressive behaviors. Other children who present with language-processing deficits may misinterpret messages and are unable to request further information or clarification, resulting in confusion and frustration. Consequently, they may demonstrate externalizing behaviors (e.g., destroying materials, physical confrontation with peers and adults), internalizing behaviors (e.g., withdrawing from interactions, self-abusive behaviors), or both. Research has yet to demonstrate a unidirectional causal relationship between communication and psychiatric disorders. However, our clinical experience indicates that for some children linguistic modifications, such as reduction in linguistic complexity, results in positive behavioral changes, suggesting that behavioral and emotional problems may be precipitated and perpetuated by difficulties in communication. The third hypothetical model goes beyond unidirectional explanations of causality between communication and psychiatric disorders. Beitchman (1985), Baker and Cantwell (1987a), and Baltaxe and Simmons (1988a) considered the possibility of a third underlying factor causing both communication disorders and psychiatric disorders. For example, Beitchman attempted to examine the role of social class variables both on language impairment and psychiatric disorders. However, the independent contributions of social class could not be determined due to its multivariate nature. Baker and Cantwell (1987a) considered common antecedents to psychiatric and communication disorders including low IQ, significant hearing loss, organic brain damage, adverse family conditions, low socioeconomic status, and significant stress in childhood. These factors have been found to co-occur with both language disorders and psychiatric disorders. Intellectual retardation, marked hearing loss, and brain damage were found in a small percentage of the sample but did not account for the differences between the psychiatrically well and the psychiatrically ill speech- and languageimpaired groups. Social class distributions were not found to be significantly different between the two groups, although an association between the total amount of all types of psychosocial stress and the presence of both psychiatric and language disorders was found. Individual family factors such as parental mental illness and family discord did not occur with sufficient frequency to test for statistical significance (Baker & Cantwell, 1987a). Baltaxe and Sim-

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184 Journal of Speech and Hearing Disorders mons (1988a) noted that prenatal, perinatal, medical, social, and family history of a child may include significant variables that play a role in the development of a communication handicap as well as a psychiatric disorder. The fourth hypothetical model, the transactional model (Sameroff, 1987; Sameroff & Chandler, 1975), addresses more specifically the mutual influence between child and environment from a longitudinal and developmental perspective. Sameroff (1987) stated, "The development of the child ... [is] seen as a product of the continuous dynamic interactions of the child and the experience provided by his/her family and social contacts" (p. 278). The child and the environment are therefore interdependent. According to Sameroff (1987), the characteristics a child displays at any point in time are never a function of the individual alone or the experience itself, and viewing a child's development in this way is misleading. For example, a child who is born with a very low birthweight (VLBW) (i.e.,

behavioral disorders in children and adolescents.

Recent research in child psychiatry has demonstrated a high prevalence of speech, language, and communication disorders in children referred to psychi...
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