Language Disorders in Children Referred for Psychiatric Services

Language Disorders in Children Referred for Psychiatric Services C. T. GUALTIERI, M.D., URSULA KORIATH, M.ED., MARY VAN BOURGONDIEN, PH.D., AND NANCY SALEEBY, M.S. Surveys of language-impaired children at speech and hearing clinics invariably show a high frequency of psychiatric disorders. However, there have been few investigations of the frequency of developmental language disorders in children referred for psychiatric services, although the presence of such a disorder would clearly be expected to influence diagnosis and treatment. In this survey of 40 consecutive admissions to a child psychiatry inpatient service, at least half of the children had moderate to severe developmental language disorders. The disorders were found in children with a wide variety of psychiatric diagnoses, and routine intellectual testing did not invariably detect the presence of developmental dysphasia. Recommendations for screening, diagnosis and treatment of language-disordered children with psychiatric problems are given. Journal of the American Academy of Child Psychiatry, 22,2:165-171,1983.

Surveys of language-impaired children have invariably shown a high frequency of psychiatric disorders [Barbara, 1960; Chess, 1944; Ingram, 1959; Karlin, 1954; McCarthy, 1954; Schlanger, 1962; Spock and Huschka, 1938; for review, see Cantwell and Baker (1977)l.Rutter (1977) found psychiatric symptoms in 44% of a sample of language disordered children; Cantwell and Baker (1980) in 53%; Stevenson and Richman (1978) in 59%;and Caceres (1971) in 84%. A wide range of psychiatric disorders is usually represented in such surveys, and language disorders do not seem to cluster in any particular psychiatric diagnostic category. For example, in Cantwell and Baker’s (1980) survey of 200 children at a community speech and language clinic, the following psychiatric diagnoses were reported: attention deficit disorder (30), avoidance disorder (16), oppositional disorder (14), adjustment disorder (lo), anxiety disorders (8), conduct disorders (7), mental retardation (7))depression (3))and autism (2). If psychiatric symptoms are prevalent in language disordered children, it is reasonable to ask if the converse may not also be true. One would expect to find a high prevalence rate of language disorders in children who are seen in psychiatric settings. The presence of a developmental language disorder in a child referred for psychiatric services would be expected to influence decisions concerning diagnosis and treatment. In fact, there has been only one report that looked at the association between language disorders and psychiatric problems from this perspective (Chess and

Rosenberg, 1974). Twenty-four percent of children referred to a psychiatrist in a private practice oriented to upper-middle class families were found to have some sort of speech or language difficulty. This paper will report the results of a second such survey conducted in seriously disturbed, lower-classchildren who were inpatients on a child psychiatry service. Developmental communicative handicaps fall into three categories:speech (stuttering, fluency, and articulation disorders); voice (disorders of resonance, pitch, and intensity); and language disorders. The latter are probably most strongly related to psychiatric problems (Cantwell and Baker, 1977). Language disorders (or “congenital aphasia,” “developmental dysphasia,” “retarded” or “infantile” or “delayed speech,” “deviant language,” “language disability, deficit, impairment, or handicap,” etc.) are characterized by slow and/or deviant development of language that is not entirely explicable in terms of sensory, motor or general intellectual deficits. Language disorders are not unitary in type or degree. The inherent complexity of the subject is compounded by rapid advances in the understanding of the neuropsychology of language systems and even more rapid changes in terminology and testing procedures. Even a straightforward term such as “receptive language” is nowadays described by language pathologists in terms of discrete processes like auditory discrimination, attention, memory, integration and comprehension. An individual child’s language skills are very seldom, if ever, reflected by a single measurement, age level or test score (Lord, 1980). Communicative handicaps are estimated to afflict, in varying degrees, approximately 10%of the population (Panel on Communicative Disorders, 1979). In one longitudinal survey, 6% of children had definite retardation in language development at age 3 years, 9 months and 5% had unintelligible speech at 4 years, 9 months (Morley, 1965).In a study of dyslexic children, 39% had deficits of receptive or expressive language (Mattis et al., 1975). Myklebust (1964) and Wood

This work was supported inpart by USPHS Grant HD-10570 to Dr. Gualtieri from the National Institute of Child Health and Human Development, Grant 77-20 to Dr. Gualtieri from the North Carolina Alcohol Research Authority, and Grant MH-33127 to Dr. Gualtieri from the National Institute of Mental Health. Special thanks to Judith Hunt and Faygele ben Miriam. Reprints may be requested from Dr. Gualtieri, Department of Psychiatry, North Carolina Memorial Hospital, Chapel Hill, NC 2 7514. oO02-7138/2201-0165 $62.00/0 0 1983 by the American Academy of Child Psychiatry. 165

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(1969) estimated that 5% of school age children have language problems severe enough to interfere with education. Articulation disorders are the most common communicative handicaps but language disorders are more common than stuttering or voice disorders. Although estimates indicate a high prevalence of communicative handicaps in general and language disorders in particular, the magnitude of the problem may still be underestimated (Panel on CommunicativeDisorders, 1979). Language disorders may represent a failure in normal development or a loss of language function because of brain injury or degenerative processes. Early psychosocial environment is known to influence the development of language, as can deafness, but in most cases the specific cause of a developmental language disorder cannot be determined. The recognition of familial patterns of language disorders has suggested nothing more specific than “polygenic” influences. The purpose of this study was to determine the frequency and severity of communicative disorders in a group of severely disturbed children referred to a child psychiatry inpatient service.

Method Subjects There were 40 admissions to the Child Psychiatry Service at North Carolina Memorial Hospital between May 1979 and July 1980. During this span of time, children were routinely referred for speech and language evaluation, unless there were specific reasons not to do so. (Reasons for not requesting a language evaluation included previous testing which was normal or exceptionally high verbal and reading skills.) There were 33 referrals for testing and 26 complete evaluations. Five children were excluded from this analysis because testing was incomplete and two because the children were moderately retarded. The 26 subjects ranged in age from 4 years 11 months to 13 years 2 months (mean = 9/4). There were 19 boys and 7 girls; 22 whites and 4 blacks. I& scores ranged from 60 to 104 (mean = 80). Twentytwo children were given the WISC-R. Verbal I&scores ranged from 52 to 100 (mean = 76) and Performance I& ranged from 57 to 108 (mean = 85). Socioeconomic status (Hollingshead) was definitely skewed towards the lowest levels: only four subjects from classes 1, 2, or 3; mean SES 4.3. Children were referred to the hospital for evaluation and intensive treatment of severe behavior problems. Children were referred from a variety of sources, and virtually all had undergone psychiatric evaluations and at least some attempt at treatment prior to admission.

Procedure Children received a comprehensive diagnostic evaluation during the first half of their inpatient stay. This included full medical, neurologic and psychiatric evaluations; a thorough evaluation of the family, and the child’shome and school environment; intelligencetesting (WISC-R or Stanford-Binet, depending on the child’s age or developmental level); an educational evaluation; audiometry; and a full speech and language evaluation. Diagnoses were given at a conference which included at least two psychiatrists (including one of the authors [C. T. G.]), as well as representatives of each of the abovementioned disciplines. The Speech and Language Evaluation An appropriate battery of tests was administered by a certified Speech and Language Pathologist (N. S.). Pure tone audiometry was done prior to language testing. (See Appendix for a description of the testing battery.) The battery of tests measured language ability in the following areas: Auditory Analysis, Auditory Memory, Auditory Integration, Receptive Language, and Expressive Language. (An explanation of these areas relative to specific tests is also given in the Appendix.) The child’s performance on each test was measured against established norms and was graded as “above average” (more than one standard deviation above the mean for mental age), “normal” (within 1 standard deviation of the mean), “mildly deficient” (more than 1 standard deviation below the mean), or “severely deficient” (more than 2 standard deviations below the mean). A global estimate of each child’s communicative deficits was made on the following basis: 1. Mild handicap: Testing in at least one area was mildly deficient; 2. Moderate handicap: Testing in at least three areas was mildly deficient, or severely deficient in at least one area; 3. Severe handicap: Testing in at least three areas was severely deficient. In addition to this “absolute” global measure of language disorder, global measures were also calculated relative to a subject’s full scale I& (FSIQ) and verbal I& scores. This was done on the basis of standard deviations (S.D.) below the mean. In category “DFS” (see table l),a score of “1” means that both language testing in any specific area yielded results that were concordant with the subject’s mental age as expressed by his FSIQ score; a score of “2” means that language testing was 1 S.D. lower than mental age; a score of “3” means that language testing was 2 or more S.D.s below the mental age. Category “DV” uses the

LANGUAGE DISORDERS IN CHILDREN

TABLE 1 Occurrence of Language Disorders in a Psychiatric Sample“

N Sex Male Female Race White Black Age Mean f S.D. SES Mean 2 S.D. FSIQ Mean -+ S.D. VIQ Mean f S.D. PIQ Mean f S.D. DX AR CDO ADD/H CDO + ADD/H

cs

SD DFS 1 (corcordant) 2 (one S.D.) 3 ( 2 2 S.D.s) DV 1 (concordant) 2 (one S.D.) 3 ( 2 2 S.D.s)

No

Mild

Moder-

LDEF

LDEF

ate LDEF

2

4

10

10

26

2

0

3 1

7 3

8 2

18 8

2 0

4 0

7 3

9 1

22 4

Severe LDEF

Total Sample

9.1 0.1

11.0 1.2

8.4 1.9

10.2 2.4

9.5 2.1

4.5 0.7

4 2

4.6 0.5

4.1 1.1

4.3 1.0

87 2.8

86.5 12.4

82.2 9.7

73.2 10.8

79.8 11.2

85.5 9.2

83.3 11.7

75 5.0

72.3 10.4

76.4 9.8

91 5.7

93.3 12.9

89.6 7.2

77.4 14.0

85.4 12.7

0 0 0 1 0 1

2 2 0 0 0 0

1 3 3 2 0 1

1 3 3 2 1 0

4 8 6 5 1 2

2 0 0

2 2 0

1 7 2

3 6 1

8 15 3

2 0 0

3 1 0

2 5 0

4 4 1

11 10 1

LDEF = language deficit, SES = socioeconomic status, FSIQ = full scale IQ score, VIQ = verbal IQ score (WISC-R), PIQ = perf‘ormanceIQ score (WISC-R),DX = diagnosis,AR = adjustment reaction, CDO = conduct disorder, ADD/H = attention deficit disorder with hyperactivity, CS = schizophrenia occurring in childhood, S D = schizoiddisorder,DFS = discrepancy (inS.D.s) between LDEF and FSIQ, and DV = discrepancy (in S.D.s) between LDEF and VIQ (WISC-R).

same system relative to verbal I& scores, for subjects who had the WISC-R.

Results Psychiatric diagnoses (DSM-111) were: Attention Deficit Disorder with Hyperactivity (ADD/H), 8; Conduct Disorder (CDO),8; ADD/H and CDO, 5; Schizoid Disorder (SD), 2; Adjustment Reaction (AR), 2, and Schizophrenia occurring in childhood (CS), 1. I& scores were in the average range for 7 subjects, borderline for 15, and mildly retarded for 4. On the basis of global ratings of language disorder,

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4 subjects had mild language disorders, 10 had mod-

erate disorders and 10 had severe disorders. Only two children had no language disorders. The language disorders occurred in all diagnostic categories, and there was no tendency for a particular psychiatric diagnosis to occur more frequently in the languagedisordered children or in the severely language-handicapped children (see table 1). Four children were found to have sensorineural hearing losses that were previously undetected. One was mild and three were moderate, and in two cases the acuity deficit compromisedthe child‘s understanding of conversational speech. The presence of language disorder would not always have been apparent from I& testing alone. No fewer than 11of 22 subjects had language testing scores that were lower than one would expect from their verbal I& scores; 18 of 26 had language scores that were relatively lower than their FSIQ scores. Thus, in a large number of children a VIQ score might be in the average range, while at least one language test area would be at least 1 S.D. below the mean; or an FSIQ score would be 1S.D. below the mean, while language testing was 2 or more S.D.s below the mean. Language tests that tended to fall below levels that would be predicted from FSIQ or verbal I& scores seemed to be in the areas of auditory analysis, memory or integration, rather than in the more general test areas of expressive or receptive language. Severely language-impaired children scored lowest on I& tests, followed by children with moderate and mild disorders and children with no disorders (see table 1).This finding may be an artifact of the I&tests that were employed. The tests were all largely language-based,even in the so-called “performance”subtests, and language-disabled children will naturally score lower on such tests. These data would be more meaningful if less language-basedI& tests, such as the Leiter International or Hiskey Nebraska, had been used especially in children with moderate or severe language disorders. Significant correlations (Pearson’s r ) were found to exist among the three measures of I& and between the IQ measures and the global measure of language disorder (LDEF; see table 2). Although verbal I& scores were negatively correlated with SES, there was no apparent statistical association between SES and other measures of language disability. Neither did there seem to be a “clustering”of language disabilities, or of any specific area thereof (e.g., auditory memory, etc.) with any specific psychiatric diagnosis. Of course, the small numbers in this sample mitigated against a comprehensive statistical treatment of these latter two points. The frequency with which language deficits were found in specific test areas is given in table 3.

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TABLE 2 Significant Correlations (Pearson’s r)” Variables FSIQ x FSIQ x VIQ x FSIQ X VIQ x PIQ x VIQ x

VIQ PIQ PIQ LDEF LDEF LDEF SES

df

r

P

20 20 20 24 20 20 20

0.88 0.90 0.64 -0.46 -0.49 -0.47 -0.49

tO.O1 tO.O1 to.01 t0.05 t0.05 t0.05 t0.05

“FSIQ = full scale I+, VIQ = verbal IQ (WISC-R), PIQ = performance IQ (WISC-R), LDEF = global measure of language disorder, and SES = socioeconomic status. TABLE 3 Specific Language Testing Areas No Deficit

Part Auditory Analysis A B Auditory Memory A B Auditory Integration A B C Expressive Language Receptive Language

-

Deficit 1 Deficit 2 2 S.D. below S.D. below

x

x

5 4

3 3

12 8

8 9

4 4

6 8

0 2 3 0 2

8 12 1 3 2

Discussion If we assume that the 14 children who did not have complete speech and language evaluations were all intact in this dimension, then we can assert that 20 (50%)of 40 consecutive admissions to a child psychiatry inpatient service had moderate to severe language disorders. Forty-five percent of the entire sample had language deficits below what one would predict based on their overall cognitive level, and at least 28% had language deficits below what one would expect from their verbal scale I& score. There appears to be a strong association, then, between developmental language deficits and severe psychiatric disorders. This is a considerably higher percentage than Chess (1974) reported in her private practice outpatient survey, although on the basis of SES alone the two groups were hardly comparable. Language disorders, then, may be as common in psychiatric populations as psychiatric symptoms are in populations of language-disordered children. Interestingly, speech and language therapists seem to be much more aware of psychiatric problems in their clients than psychiatrists and psychologists are of language disorders in theirs, explained perhaps by the fact that psychiatric problems are usually quite readily apparent while the presence of even severe language

disorders may sometimes be demonstrated only by highly specialized tests. It does not seem, however, that psychiatrists have begun to grapple with this new dimension in diagnosis and treatment, in spite of the fact that so many psychiatric approaches are strongly language-based. In a recent survey of 22 psychiatric educators, for example, only two respondents felt that familiarity with communicative disorders was an essential part of residency training (Bowden et al., 1980). A thorough understanding of developmental problems, especially the language and communication disabilities, and their crucial role in influencing a child’s experience of the world can make diagnosis more accurate and treatment prescriptions more germane. A dynamic formulation ought to consider not only a patient’s experiencesand his relationships but also the cognitive equipment with which he perceives his environment, interprets and remembers it, and responds to it. We have had such success with this combined developmental/psychiatric approach to severely disturbed children that we have adopted an (admittedly) extreme stance that no psychiatric diagnosis is appropriate in a severely disturbed child until a thorough developmental assessment is in hand. Language assessment is an essential aspect of this because the information provided by this evaluation has a profound impact on one’s understanding of behavioral symptoms, the treatment thereof, and the interpretation of the child’s problems to parents, teachers, and other caretakers. When attempting to assess the nature and severity of a child’s emotional problems, the examiner must be cognizant of the child‘s language capabilities. The traditional tools used to assess a child‘s emotional development are all strongly language-based:the mental status examination, play interviews, and projective tests. We are inclined to question the validity of these highly language-basedinstruments for evaluating children with language disabilities. For example, eight children in this sample were referred with “psychotic” or “borderline” diagnoses. These “labels”were applied primarily on the basis of verbal responses in an unstructured interview or projective testing. Only one child met DSM-I11 criteria for “schizophrenia occurring in childhood,” two for “schizoid disorder,” none for “borderline personality disorder”; the other five children had relatively “milder” psychiatric problems that were compounded by moderate to severe language disorders. It is not uncommon for children with such language disabilities to appear extremely disorganized and agitated in an unstructured verbal situation when they cannot completely comprehend or respond to the language stimuli with which they are confronted, and this behavior may easily be misinter-

LANGUAGE DISORDERS IN CHILDREN

preted as “psychotic” or “borderline.” But these same children will present quite a different clinical picture when language demands are made at an appropriate level. By taking advantage of information supplied by psychologicaland psycholinguistic evaluations,the clinician should be able to appraise the psychiatric status of such children without taxing unduly their limited linguistic resources. Understanding a child’s language disability will not only influence the diagnostic process, but it also may help determine the best treatment approach to behavior or emotional problems. Psychotherapy for children is often based on the dual assumptions that the child has normal understanding and use of language and that language is isomorphic with thought. Even play therapy will often assume that the child is able to process and act on the interpretations or symbolic interventions of the therapist. For a child with a severe language handicap, such a situation is not only likely to be ineffective, but may also be confusing and stressful. In most language disordered cases in this sample, there was a marked improvement in psychotherapy sessions when therapists became aware of the child’s verbal limitations. For example, a 10-year-oldboy was referred with a tentative diagnosis of psychosis based on his peculiar responses in projective testing and free play therapy sessions. During initial therapy sessions in the hospital, this child was extremely active and talkative. Questioning and problem-solving approaches often led to inappropriate and peculiar verbal responses. A speech and language evaluation revealed that he had a mild to moderate sensorineural hearing loss and difficulties with auditory memory and sequencing. The child’s talkativeness belied a severe deficit in his comprehension of language. When the therapist lowered his expectations of high level verbal responses and added visual cues (pictures and drawings), the child’s activity level decreased and he was able to work with the therapist. He was able to draw pictures of problem situations (e.g., being teased by peers) and then draw alternative ways of dealing with frustration and anger. Practicing these alternative behaviors through role play in individual sessions led to generalizationto group situations. Another 10-year-old boy had difficulty separating from his mother. Attempts to deal with this behavior verbally simply intensified his anxiety. A previous interpretation of the situation had led other clinicians to diagnose a “symbiotic psychosis.” Unfortunately, this term was of no value for understanding the genesis of the problem or for generating treatment approaches. Our clinical suspicion was that the child’s cognitive and language deficits made it difficult for him to understand why his mother was leaving and to

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know when he would be seeing her again. In fact, we learned that he did not understand the words staff had been using to reassure him or the time concepts we used to explain when his mother would return. By simplifying the language of caretakers, using a calendar as a pictorial guide and rehearsing separation situations with him, the separation problems quickly resolved. These same basic approaches have proven to be very helpful in the day to day management of troublesome behavior on the ward and in the child’s various activities. For example, a number of the languageimpaired inpatients have had difficulty with transitions from one activity to another. Verbal explanations are not sufficient for preparing such children for transitions. Simplifying language and using calendars and pictorial charts is helpful. One language-handicapped child threw a tantrum every time activities changed; giving him an object to take to a staff person at the next activity dramatically reduced the tantrums. When language-impaired children become disorganized, verbal commands or prompts have a limited effect on on-task behavior. Pictorial checklists help some of these children to organizetheir responsibilities better. Simplifying verbal approaches and using gestures, touch, expression, tone of voice cues, and nonverbal techniques such as drawings, charts and role playing are effective therapeutic techniques in working with language-handicappedyoungsters. Clearly, not every child with emotional or behavior problems has a language or communication handicap. But the inpatient service described here is by no means atypical in its referral and admissions policies, and we have a strong suspicion that similar surveys of other samples of severely disturbed children will show similar patterns for language disorders. What is most important about the diagnosis of a language handicap is that it is prescriptive: understanding a child’s psycholinguistic difficulties gives one an important guide for managing difficult behavior and for resolving emotional problems. Disorders of the development of language are likely to be central to the developmentof human personality. Understanding and correcting deficienciesof language can improve behavior and help a child resolve at least some of his emotional dilemmas. Failing to recognize a moderate or a severe language disability will almost certainly work to a child’s disadvantage in therapy, and afterward.

Appendix A. The Test Battery for Auditory and Language Function 1. Goldman-Fristoe-Woodcock (GFW) Auditory Skills Test Battery (Woodcock, 1976)

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2. Fisher-Logemann Test of Articulation Competence (Fisher and Logemann, 1971) 3. Detroit Test of Learning Aptitude (DTLA) (Baker and Leland, 1967) 4. Test for Auditory Comprehension of Language (Carrow, 1973) 5. Denver Auditory Phoneme Sequencing Test (DAPST) (Aten, 1979) 6. Auditory Analysis Test (Rosner and Simon, 1971) 7. Auditory Integrative Abilities Test (Grote, 1976) 8. Woodcock-Johnson Psychoeducational Battery (W-JPB) (Woodcock and Johnson, 1977) 9. Structured Photographic Language Test (Werner and Kresheck, 1974) 10. Arizona Articulation Proficiency Scale (Fudula, 1963) 11. Token Test (revised) (McNeil and Prescott, 1978) 12. Illinois Test of Psycholinguistic Abilities (revised) (ITPA) (Kirk et al., 1968) 13. Peabody Picture Vocabulary Test (Dunn, 1965) 14. Semantic Oppositional Rhyming Retrieval Test (SORRT) (Logue and Dixon, 1979)

B. The Organization of the Test Battery 1. Auditory Analysis Part A: Ability to discriminate a verbal stimulus in quiet and with competing background noise. Tests: Auditory Discrimination, GFW (Quiet) DAPST, Part I (discrimination in quiet) Selective Attention, GFW (discrimination in noise) Part B: Ability to analyze the relationship of phonemes within a word; for example, to identify the position of a phoneme within a word; to repeat nonsense symbols; or to repeat a multisyllabic word. Tests: Sound Analysis, GFW Auditory Analysis Test Sound Mimicry, GFW Auditory Closure, ITPA 2. Auditory Memory Part A: Recognition of previously heard words, auditory memory for content. Tests: Recognition Memory, GFW Memory for Content, GFW Token Test, Part V Auditory Attention for Related Syllables, DTLA Part B: Sequential memory-temporal sequencing. Tests: Auditory Sequential Memory, ITPA Token Test, Parts I-IV DAPST, Part I1 Auditory Attention for Unrelated Syllables, DTLA

3. Auditory Integration Part A: Sound recognition and sound blending: the ability to take successive sounds and integrate them into a meaningful word; or to repeat a specific sound pattern, for example, rhythmic clapping. Tests: Sound Recognition, GFW Sound Blending, GFW, ITPA Auditory Integrative Abilities Test, Parts I11 and IV Part B: Sound/symbol association; the ability to incorporate an auditory stimulus with a visual symbol. Tests: Auditory Integrative Abilities Test, Parts I and I1 Sound/Symbol Association, GFW Reading of Sound and Spelling of Sounds, GFW Part C: Reasoning skills relative to auditory information; for example, following verbal directions; analogies. Tests: Auditory Association, ITPA Auditory Reception, ITPA Oral Directions, DTLA Oral Commissions, DTLA 4. Receptive Language: Auditory comprehension of language; for example, associating a verbal stimulus (word) with a visual symbol (picture). Tests: Peabody Picture Vocabulary Test Test for Auditory Comprehension of Language Oral Directions 5. Expressive Language: Quality of verbal productions; for example, filling in the blank, or responding to a key word with an antonym, a synonym or a rhyming word. Tests: Arizona Articulation Proficiency Scale Grammatic Closure, ITPA SORRT (Semantic Oppositional Rhyming Retrieval Test) Language Sample (analysis by method of Tyack and Gottsleben, 1974) Structured Photographic Language Test Fisher-Logemann Test of Articulation Competence The clustering of various subtests of established measures of language function is somewhat idiosyncratic at our Speech and Language Laboratory, but is based upon a graduated assessment of language function. For example, discrimination of verbal sounds in noise is a relatively unsophisticated auditory function, whereas the ability to follow oral directions is a relatively sophisticated auditory function. There is a certain redundancy among these tests, and several sub-

LANGUAGE DISORDERS IN CHILDREN

tests were often applied within a given area (for example, sound discrimination) to confirm the findings on other tests. The choice of tests was necessarily individualized, according to the child's age and developmental level, his processing time (for tests that are presented on audiotape), the ambiguity of the results, the child's level of cooperation, and the availability of norms. Testing usually occurred over several days, and a complete battery would take from 6 to 30 hours.

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