Language and Behavior Disorders in School-Age Children: Comorbidity and Communication in the Classroom Language development is the foundation for competence in social, emotional, behavioral, and academic performance. Although language impairment (LI) is known to co-occur with behavioral and mental health problems, LI is likely to be overlooked in school-age children with emotional and behavioral disorders (EBD; Hollo, Wehby, & Oliver, in press). Because ... Article
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Article  |   December 01, 2012
Language and Behavior Disorders in School-Age Children: Comorbidity and Communication in the Classroom
Author Affiliations & Notes
  • Alexandra Hollo
    Department of Special Education, Vanderbilt University, Nashville, TN
  • Disclosure: Alexandra Hollo has no financial or nonfinancial relationships related to the content of this article.
    Disclosure: Alexandra Hollo has no financial or nonfinancial relationships related to the content of this article.×
Article Information
School-Based Settings / Language Disorders / Articles
Article   |   December 01, 2012
Language and Behavior Disorders in School-Age Children: Comorbidity and Communication in the Classroom
SIG 16 Perspectives on School-Based Issues, December 2012, Vol. 13, 111-119. doi:10.1044/sbi13.4.111
SIG 16 Perspectives on School-Based Issues, December 2012, Vol. 13, 111-119. doi:10.1044/sbi13.4.111

Language development is the foundation for competence in social, emotional, behavioral, and academic performance. Although language impairment (LI) is known to co-occur with behavioral and mental health problems, LI is likely to be overlooked in school-age children with emotional and behavioral disorders (EBD; Hollo, Wehby, & Oliver, in press). Because language deficits may contribute to the problem behavior and poor social development characteristic of children with EBD, the consequences of an undiagnosed language disorder can be devastating. Implications include the need to train school professionals to recognize communication deficits. Further, it is critically important that specialists collaborate to provide linguistic and behavioral support for students with EBD and LI.

Language development is the foundation of, and intertwined with, adaptive academic, social, and behavioral performance. It is perhaps not surprising, therefore, that children with language impairment (LI) are at increased risk for learning and behavioral disorders. According to one estimate, more than half of children with diagnosed language disorders also have an emotional or behavioral disorder (Benner, Nelson, & Epstein, 2002). It is perhaps less commonly recognized, however, that language disorders are frequently overlooked in children with diagnosed emotional and behavioral disorders (EBD). In fact, 4 out of 5 students with EBD are likely to have an unidentified language deficit (Hollo, Wehby, & Oliver, in press). For the present discussion, the broad terms language deficit or impairment are used to denote low language ability, whether or not students have a formally diagnosed language disorder or disability.
Consequences of unidentified LI can be serious for children with EBD, who may resort to physical means to communicate wants and needs or resolve conflicts. Adults' failure to recognize the communicative function of problem behavior may contribute to negative teacher-student interactions and decreased academic achievement. The effects of these factors on school failure, drop out, and delinquency are unknown. What is known is that compared to all other disability groups, children and youth with EBD have the most negative short-and long-term outcomes (Wagner, Kutash, Duchnowski, Epstein, & Sumi, 2005). In this review, I will present an overview of characteristics of students with EBD, including prevalence, severity, and types of language deficits. I will also provide strategies to support communication and instruction for children with low language performance and problem behavior.
Characteristics of Students with Emotional and Behavior Disorders
Researchers often use EBD as an umbrella term that includes children who receive receive clinical or educational services due to chronic and severe maladaptive behaviors, as well as children who are considered at risk for identification through school or community-based systems. When formally identified through clinical settings (e.g., inpatient or outpatient, psychiatric or mental health), children may receive a medical diagnosis according to criteria outlined in the Diagnostic and Statistical Manual (e.g., DSM-IV; American Psychiatric Association, 2000). Diagnoses may include internalizing (emotional, withdrawn, overcontrolled) disorders such as depression, anxiety, or mood disorders, or externalizing (behavioral, disruptive, undercontrolled) conditions such as attention deficit/hyperactivity disorder, oppositional/defiant disorder, or conduct disorder.
Although as many as 20% of school-age children may have serious mental health needs, only 1–2% receive special education services under the disability label emotional disturbance (ED; Gresham, 2007). The ED label may be assigned either instead of or in addition to one or more psychiatric diagnoses. The definition of ED used to identify children who qualify for educational services is outlined in the Individuals with Disabilities Education Act (IDEA, 2004). The IDEA definition is not aligned directly with the DSM and specifies that problem behavior must interfere with school performance. Although the term emotional disturbance does not include the word behavioral, it is relevant to note that students with externalizing disorders are more likely to receive school-based services than students with internalizing disorders (Kerr & Nelson, 2010). In this paper, the term EBD does not include at-risk students, but references children and youth who have been formally identified and receive services in educational or clinical settings.
Academic Achievement
Both internalizing and externalizing topographies of problem behavior have been linked to poor academic performance, particularly in the keystone skill of reading (Tomblin, Zhang, Buckwalter, & Catts, 2000). Children with primarily internalizing EBD tend to have high rates of absenteeism and low achievement (DeSocio & Hootman, 2004), perhaps stemming from anxiety related to academic or social pressures inherent in school settings. For students with externalizing disorders, disruptive behavior effectively impedes or even terminates instruction. Academic achievement for students with EBD typically is below that of other students with disabilities—even though performance profiles on standardized assessments are similar to those of students in other disability categories (Smith, Katsiyannis, & Ryan, 2011).
Many researchers have noted a large degree of overlap in characteristics of children with language, learning, and behavioral disorders. There is even some overlap in definitions: ED, LD, and specific language impairment (SLI) all specify that children must have either an inability to learn or poor school performance in the absence of neurological or cognitive impairment (IDEA, 2004; Tomblin et al., 1997). An important difference is that behavior management is often a priority over instruction for students with EBD. Unfortunately, the focus on behavioral over academic and social skills interventions only perpetuates the cycle of school failure.
Social Skills
Poor social functioning has been identified as problematic for children with language and learning disabilities, but is a hallmark characteristic of children with EBD. In the social domain, language is the basis for developing interpersonal relationships. Indeed, communication skill may be considered a defining factor of social competence (Rinaldi, 2003). Conversational ability is central to skills such as initiating, developing, and maintaining friendships; problem-solving; cooperation; and conflict resolution. Through use of internal dialogue or self-talk, language also is related to the capacity for self-control, self-reflection, emotion regulation, and response inhibition (Brinton & Fujiki, 2011; Donahue, Cole, & Hartas, 1994; Gallagher, 1999). Language skill thus influences children's ability to control their temper, follow directions, ignore distractions, and transition between activities. Deficits in these areas affect ratings of overall social competence, which have shown that children with EBD are likely to be rejected and even victimized by peers (Wagner et al., 2005). Relationships with adults suffer as well: Interactions with teachers are likely to be characterized as negative, particularly for students with externalizing behaviors such as aggression (Van Acker, Grant, & Henry, 1996).
Comorbidity of Language and Behavior Disorders
The term comorbidity references the occurrence of one or more conditions within an individual, regardless of the underlying causes or origins of either condition. Although causal or directional mechanisms are largely theoretical, the overlap between communication and behavioral disorders has become a generally accepted phenomenon (Tomblin & Mueller, 2012). Nevertheless, many scholars have noted that LI tends to be unnoticed in children who exhibit challenging behavior. To determine the extent and severity of the problem, Hollo, Wehby, and Oliver (in press) conducted a meta-analysis of 22 studies reporting results of language assessments in children with EBD and no prior history of language impairment. The researchers used conservative inclusion criteria to avoid inflating prevalence estimates and to limit alternative explanations for results. In included samples, LI was not attributable to general developmental, cognitive, neurological, or attention disorders. Students included in primary studies were assessed only because they were participants in a research study or as a standard protocol for admission to a psychiatric or behavioral clinic. That is, none of the assessments were conducted as part of an educational evaluation. The methodology allowed for analysis of prevalence, or comorbidity of LI, as well as severity.
Contrary to expectations, results indicated that prevalence of LI was higher than an earlier estimate of 71% in a more broadly defined sample of children with EBD (Benner et al., 2002). Hollo and colleagues (in press) reported that 80.6% [95% CI 76, 84] of children with EBD and no history of LI in fact had below average language performance, defined as clinical designation of mild-severe LI or scores below 85 on a comprehensive standardized assessment. Nearly half the participants (46.5% [36, 57]) were classified as having moderate to severe LI, defined as a clinical diagnosis or standard score below 70. In all cases, the only assessments reported that also met inclusion criteria were versions of the Clinical Evaluation of Language Fundamentals (CELF; e.g. Semel, Wiig, & Secord, 2003) or the Test of Language Development (TOLD; e.g. Hamill & Newcomer, 1997). Examination of mean standardized test scores supported the conclusion that language skills of children with EBD are significantly below average: The overall mean score was 76.33 [71, 82]. Scores obtained from the CELF (74.77 [62, 87]) and the TOLD (77.18 [70, 84]) were not statistically different from one another.
In the Hollo and colleagues (in press) meta-analysis, prevalence of LI in children with EBD identified and treated in school settings was 57% compared to 39% of children in clinical settings. It is unclear whether this 18% difference reflected study or participant characteristics. Moderator analyses revealed school-based studies were more likely to report a single measure to establish case status, whereas clinical studies more often included a battery of measures that included naturalistic assessments and the judgment of a licensed SLP. Although between-group differences may have been attributable to the method of assessment, there also may be true differences in language skills of children served in schools or clinics. As stated earlier, children with externalizing behavior are more likely to receive educational services than those with internalizing behavior. It is possible that differences in LI between settings actually reflected differences in type of problem behavior; however, the authors were unable to assess this hypothesis empirically.
Some studies included in the meta-analysis also reported outcomes for expressive and receptive language. Generally, participants had more difficulty with language production than comprehension. Prevalence of generally below-average performance was higher and mean scores were lower for expressive skills (85.7%; M=75.9 [69, 83]) compared to receptive (64.3%; M=82.2 [77, 87]). This pattern was repeated in the categories for mild and moderate/severe deficits. This result was somewhat surprising, as several scholars have indicated that receptive skills may be more strongly related to problem behavior than expressive (Benner et al., 2002; Cohen, Davine, Horodezky, Lipsett, & Isaacson, 1993; Hollo et al., in press). Expressive deficits also have been characterized as more conspicuous than problems with comprehension, so it was expected that lower receptive skills would explain why LI is so often overlooked in this population. It is possible that students with EBD are adept at producing relatively simple forms of language, but rely on problem behavior to express complex thoughts and emotions such as the confusion, frustration, or embarrassment that occurs when comprehension fails.
Implications for Communication in the Classroom
Results of the meta-analysis by Hollo, Wehby, and Oliver (in press) suggest that the majority of children with EBD have generally low language skills, and more than half of those served in school settings are likely to have clinically significant deficits that go unrecognized. For children with EBD, undetected language deficits may have serious repercussions. It is important to note that many interventions are verbally mediated, and therefore may be ineffective or even countertherapeutic for children with EBD and low language ability (Javorsky, 1995). In addition, differences between adults' expectations and student's capabilities may increase negative interactions in educational and therapeutic settings. If children produce limited, yet relatively functional language, adults often assume that they have the ability to use verbal rather than behavioral communication strategies. In turn, adults may perceive problem behavior as deliberate disrespect, inattention, dishonesty, noncompliance, or defiance (Donahue et al., 1994). Such characterizations may add stress, frustration, and blame to social and instructional interactions that are already likely to be challenging for all parties, and may contribute to negative classroom interactions. Additionally, adults who use complex or unclear language structures may inadvertently contribute to increases in problem behavior. That is, students may withdraw when confronted with incomprehensible verbal demands or may engage in problem behavior as a functional communication strategy.
Linguistic Supports
Identifying students' specific linguistic strengths and weakness may provide a foundation on which to build supports for children with emotional and behavioral disorders. Following a comprehensive evaluation of students' language performance, supports should include evidence-based interventions to address students' linguistic limitations. The effects of language intervention on student behavior are as yet unknown, but several authors have offered service delivery options for students with LI and EBD (e.g., Armstrong, 2011; Audet & Hummel, 1990; Keefe, Hoge, Shea, & Hoenig, 1992; Sanger, Moore-Brown, Montgomery, & Larson, 2002; Theadore, Maher, & Prizant, 1990). Although an in-depth review is beyond the scope of this paper, some general concepts and strategies are provided here. These include both direct (student centered) and indirect (adult centered) intervention.
Direct intervention. Children with expressive deficits may be hesitant to use language in academic or social situations, increasing a tendency toward anxiety or social withdrawal. Conversely, children who have difficulty with verbal communication may tend to act out to access attention or tangible items (positive reinforcement) or avoid unpleasant tasks or situations (negative reinforcement). Students with EBD also are likely to have difficulty in comprehension and use of pragmatic (Hyter, Rogers-Adkinson, Self, Simmons, & Jantz, 2001; Rinaldi, 2003) and nonliteral language (Mack & Warr-Leeper, 1992). Regardless of the specific type of language deficit or behavioral manifestation, it is likely that all children with EBD will benefit from explicit instruction in the language of emotion, including how to use the vocabulary of emotion (feeling words) to encourage self-regulation through self-talk (Brinton & Fujiki, 2011). Students also need good models of communicative competence and opportunities to use language to negotiate academic and social interactions. It may seem counter-intuitive to use peer-mediated strategies with students with EBD, because they are often excluded from interaction with typical peers. In fact, cooperative learning and other peer-mediated interventions have been shown to be effective with this population (Ryan, Reid, & Epstein, 2004).
Indirect intervention. In addition to providing direct intervention to children with EBD, support also should include collaboration with and training for teachers. The first step in working with teachers may be simply to provide information about the nature and extent of the child's language deficit. Anecdotally, researchers have noted that simply recognizing that problem behaviors could be in part due to deficits in language comprehension helps adults become “less likely to fault the children for their misbehavior” (Cohen et al., 1993, p. 600) and more likely to perceive the child “in a more positive light” (Gallagher 1999, p. 7). Researchers in second language acquisition and other fields have demonstrated that adults often adapt oral language use when they are aware that conversational partners are not linguistically proficient (Owen, 1996). If simply altering adults' expectations and verbal output could affect meaningful change in daily academic, social, and behavioral interactions, outcomes for children with EBD could be significantly and efficiently improved.
The second step in working with teachers may be encouraging them to modify their own use of language in the classroom. Researchers have hypothesized that there is a mismatch between adults' use of oral language and children's ability to comprehend or reproduce it (Harrison, Gunter, Reed, & Lee, 1996). That is, children with EBD and low language skills may experience teacher talk as an aversive stimulus and may engage in problem behavior to avoid verbal interactions. Teachers initially may respond by increasing demands, followed by escalating problem behavior by the student, until the behavior is so disruptive it effectively terminates instruction. In the future, teaches may learn to avoid the behavior by decreasing instruction. This cycle of coercive interactions in the classroom has been called a negative reinforcement trap, and has been well documented in classrooms for children with EBD (Sutherland & Morgan, 2003).
Adapting teachers' language may increase the probability students with receptive deficits will comprehend and engage in instruction, perhaps decreasing occurrences of challenging behavior. Teachers must realize the importance of providing good models of oral language use. Recommendations include speaking in complete, uninterrupted sentences that are free of mazes (fillers, false starts, hesitations, revisions); using concrete referents and explicit examples; monitoring nonliteral language such as idioms, puns, or sarcasm; and explaining multiple meanings when necessary. Although it is also important to model use of sophisticated grammatical forms and rich vocabulary, teachers must balance use of complex forms of language with simple, direct, and clearly stated explanations and directions.
Reducing the rate of teacher talk also may be an important target for change. In a laboratory study, Montgomery (2005) demonstrated that children with SLI benefitted when material was presented at a slower speed. He noted that children with language impairment have inefficient processing skills, even beyond what can be predicted by receptive language skills. In a descriptive study of language samples of 22 elementary school general and special education teachers, Hollo and Wehby (2011) also suggested that K–4 teachers who spoke at higher rates also tended use more vagueness markers, including mazes; abstract, ambiguous, or figurative language; and grammatical or content errors. Analysis of lessons during whole-group instruction showed that 73% of all teacher speaking turns contained at least one marker of vagueness; however, there were no significant differences between general and special educators on any of the measures of rate, quantity, content, complexity, or clarity.
Behavioral Supports
Two surveys administered to SLPs (Parow, 2009; Sanger et al., 2002) have identified several barriers to working effectively with children with EBD. A particular concern for SLPs was lack of training in working with highly inattentive, disruptive, or aggressive students and the resulting lack of confidence in their ability to provide services for children with EBD. The importance of collaboration with special educators, therapists, and behavioral consultants cannot be understated. For example, behavioral consultants can help identify the communicative function of problem behavior and help develop interventions to replace problem behavior with adaptive behaviors. Again, interventions may be focused on child behaviors (e.g., teaching students to request breaks, recruit positive attention, or self-monitor) or adult behaviors (increasing noncontingent attention, minimizing attention for problem behavior, using precorrections and organizational strategies). Seeking professional development opportunities in behavior management strategies also will help SLPs improve services to all children, not just those with EBD. There are many specific evidence-based interventions to increase adaptive behavior and decrease problem behavior. I provide an overview of three general strategies here that are particularly salient for children with EBD and LI.
Explicit instruction. For children with problem behavior and communication deficits, it is important to structure the environment to minimize distractions and maximize predictability (Sprick, 2009). Establishing, explicitly teaching, and practicing routines and procedures will help prevent problem behavior, particularly surrounding transition times. It is also important to make the hidden curriculum visible by systematically and explicitly teaching rules that apply in the classroom and other school settings. Teachers should state rules positively, clearly communicate 3–5 behavioral expectations, and include feedback, error correction, and progress monitoring (Conroy, Sutherland, Snyder, & Marsh, 2008; Sprick, 2009). Once instructors have established rules, they can use a group contingency such as The Good Behavior Game (Barish, Saunders, & Wolf, 1969) to encourage class-wide rule-following behavior. The Good Behavior Game has an extensive research base and can be adapted in many ways in many settings (Elswick & Casey, 2011; Tankersley, 1995).
Other strategies that use verbal and nonverbal modifications to promote compliance are Effective Instruction Delivery (EID; Everett, Olmi, Edwards, & Tingstrom, 2005) and Precision Requests (De Martini-Scully, Bray, & Kehle, 2000). Components of these interventions include explicit wording of behavioral requirements, proximity, eye contact, and wait time, as well as procedures for following through with requests and reinforcing compliance. These strategies may reduce linguistic demands because they include brief, positively stated verbal statements that are cued using consistent phrases and gestures. Following each statement, a 3–5 second wait time allows students time to process the information and act accordingly.
Opportunities to respond. An effective and efficient way to decrease problem behavior is to provide reinforcement for engaging in an incompatible behavior, such as participation in instruction. Increasing opportunities to respond (OTR) is an evidence-based strategy for promoting adaptive behavior and increasing achievement (Moore Partin, Robertson, Maggin, Oliver, & Wehby, 2010). SLPs can increase OTRs in many ways, such as individual or choral responding through verbal or nonverbal (eg., gestures, response cards) means. The strategies SLPs use should include features of effective instruction such as prompts that are taught explicitly and used repeatedly, wait time for students to formulate a response, and frequent comprehension checks and feedback (Conroy et al., 2008). Increasing OTRs may be particularly important for children with EBD and LI because it has the inverse effect of decreasing the amount of teacher talk students must process (Hollo & Wehby, 2011). That is, rapid presentation of small chunks of information prevents long, uninterrupted, lectures, which may overload attention, working memory, and other cognitive resources (Montgomery, 2005).
Effective praise. The oft-heard admonishment to “catch ‘em being good” is certainly good advice, but is perhaps incomplete. A more effective way to increase a desired behavior is to use descriptive praise that is contingent on a specific behavior (Conroy et al., 2008; Moore Partin et al., 2010). SLPs can use praise to increase academic or social behaviors. SLPs can replace the overused “good job” with behavior-specific praise statements such as “Great answer, and you answered using a complete sentence,” or “I can tell you've been paying attention because you followed directions so well.” It is also helpful to employ natural contingencies of positive behavior such as access to attention or preferred activities, such as “You finished your work quickly and accurately so now we have time for a game.” It is important to note that students with behavioral disorders may not react as anticipated when showered with praise. It is important to consider the age of the student, and what behavior is being reinforced. Students who act out may react poorly to being publicly praised for exhibiting a skill they consider to be “babyish.” For students who are shy and withdrawn, any extra attention may be excruciating.
Conclusion
Prevalence of LI in children with EBD is far higher than the 3% to 14% found in the general population of school-age children (Law, Boyle, Harris, Harkness, & Nye, 2000; Tomblin et al., 1997). It is evident that language, learning, and behavior problems are likely to co-occur regardless of students' educational status as ED, LD, or SLI, and that deficits in each area contribute to poor academic and social outcomes. Nevertheless, providers of school-based services may approach language, learning, social, emotional, and behavioral concerns as separate entities. It is critically important that school professionals work together to identify and support children with these dual deficits. In the absence of an interdisciplinary approach to identification and treatment, it is likely that LI will continue to be unrecognized and unremediated in children who exhibit problem behavior. The role of SLPs in supporting students and teachers is vital to promoting positive outcomes for students with LI and EBD.
To promote identification of children with co-occurring LI and EBD, SLPs should share information about comorbidity with teachers, psychologists, social workers, and behavioral consultants. Collaboration with these professionals will be mutually beneficial, as adults who work with students with EBD will be an invaluable source of information about evidence-based behavior management strategies. To prevent students' behavioral difficulties from interfering with assessment and intervention efforts, SLPs must become confident in understanding and applying these strategies. In turn, SLPs can help school professionals appreciate the importance of language in developing age-appropriate skills for navigating academic and social environments. Adults must understand that just as toddlers may engage in tantrums to communicate wants, needs, and emotions, older students also may lack the ability to negotiate interactions verbally. It is incumbent upon all school-based professionals to identify LI in students with EBD, to prevent breakdowns in communication whenever possible, and to recognize when problem behavior is a result of failure to communicate.
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