Incidence of spoken language disorders refers to the number of new cases identified in a specified time period. No reliable data on the incidence of spoken language disorders in children were located.

Prevalence of spoken language disorders refers to the number of people who are living with a spoken language disorder in a given time period. The variability in prevalence estimates below is attributed to differences in how spoken language disorders are defined, the nature of the population studied, variations in the methodological procedures used, and the over-identification and under-identification of children from historically marginalized or minoritized populations (Laing & Kamhi, 2003; Law et al., 2000; Norbury & Sparks, 2013; Pinborough-Zimmerman et al., 2007).

Studies of 4- to 5-year-old children in the United Kingdom, Australia, Canada, and Germany have estimated the prevalence of any spoken language disorder, either those that occur as a primary disorder or those that are secondary to a medical condition or diagnosis, to fall between 6.6% and 20.6% (Beitchman et al., 1986; Norbury et al., 2016; Reilly et al., 2010; Weindrich et al., 2000). For 7- to 11-year-olds in Australia and Germany, the prevalence of spoken language disorder was 3.4%–18.9% (Eadie et al., 2021; McKean et al., 2017; Weindrich et al., 2000).

The following studies of developmental language disorder (DLD) estimate the prevalence of spoken language disorder that cannot be attributed to a medical diagnosis or condition. For 4- to 6-year-olds in the United Kingdom and China, the prevalence of DLD was 7.58%–8.5% (Norbury et al., 2016; Wu et al., 2023). Another study found that the prevalence of DLD was 6.4% at 10 years of age for children in Australia (Calder et al., 2022). Assuming a 7.5% prevalence rate, the estimated number of cases of DLD in the United States in 2019 was 5,461,200 (McGregor, 2020).

The prevalence of specific language impairment for kindergarten children has been widely cited as 7.4% overall in the United States (Tomblin et al., 1997). This study’s use of the term “specific language impairment” refers to children who exhibit a language disorder but score within normal limits on nonverbal intelligence tests (Tomblin et al., 1997). It should be noted that the use of intelligence test score discrepancies to determine eligibility for language services is not a practice supported by ASHA. See the Cognitive Referencing section below for further explanation and a link to ASHA’s resource on this topic.

Studies reported results based on gender; however, there were no indications whether the data collected were based on sex assigned at birth and/or gender identity. In 4- to 5-year-old children, the prevalence of spoken language disorder, which may or may not be associated with a diagnosed medical condition, was higher in boys (Beitchman et al., 1986; Weindrich et al., 2000). The prevalence of DLD in 4- to 10-year-old children was also higher in boys, but the differences were not significant (Calder et al., 2022; Norbury et al., 2016).

Co-Occurring Conditions or Diagnoses

Behavioral Disorders

For children aged 5–13 years who had been formally identified with emotional and behavioral disorders, 81% were considered to have a language disorder, with 34% having a mild language disorder and 47% having a moderate–severe language disorder (Hollo et al., 2014).

Attention-Deficit/Hyperactivity Disorder and Executive Function Differences

In children in the United States, the rate of co-occurrence of attention-deficit/hyperactivity disorder and DLD is estimated to be 22.35% (Redmond, 2020). Compared with children without DLD diagnoses, children with DLD often demonstrate poorer executive functions (e.g., working memory, inhibition, shifting). However, there is considerable individual variability, and not all people with DLD demonstrate deficits in executive functions (Kapa & Erikson, 2019; Pauls & Archibald, 2016; Vissers et al., 2015).

Reading/Writing Disorder

Many children with spoken language disorders also have difficulty with reading/writing. Adlof et al. (2017) found that 54% of children with DLD also had dyslexia. At the same time, 71% of children with dyslexia had DLD. Although rates vary across studies, other researchers have made similar findings. For 7- to 9-year-old children with reading disorder in Norway, 46% were found to have language disorders (Helland et al., 2016). Of children in the United States diagnosed with language disorder, 27% were classified as poor readers by the end of kindergarten (Murphy et al., 2016).

Autism

In a sample of 8-year-old children on the autism spectrum in the United States, 23.6%–63.4% were found to have language disorder (Levy at al., 2010; Rubenstein et al., 2018). About 30% of school-age children and adults on the autism spectrum use only a few words or phrases (Schaeffer et al., 2023).

Speech Sound Disorders

In 4-year-olds with speech sound disorder in Australia, the comorbidity of DLD was 40.8% (Eadie et al., 2015).

Additional Considerations

Risk Factors Related to Social Determinants of Health

Several studies considered language disorders in the context of factors related to social determinants of health.

One study by King et al. (2005) considered households in the United States with risk factors such as inadequate income or housing, poor prenatal care, inadequate social supports, history of substance abuse, or history of mental health issues. The authors found that 10% of 3-year-olds living in these households had severe language delays (at least 2 SDs below average on a composite language test) and 49% had at least mild language delays (1 or more SDs below average).

In an Australian cohort of 5-year-olds living in households with risk factors such as mothers with no support, poorer health, no high school degree, no household income, or no previous employment, 24.9% presented with language difficulties as defined by scoring 1.25 or more SDs below average on a core language test. Had the authors used a less conservative cutoff of 1 or more SDs below average, the prevalence would have been 32% (J. Smith et al., 2021).

See ASHA’s resource on social determinants of health.

Signs and symptoms of spoken language disorders vary across individuals, depending on

• the language domain(s) affected,
• the severity and level of disruption to communication,
• the age of the individual, and
• the stage of linguistic development.

On occasion, a young child may show a delay in language emergence with no other diagnosed disabilities or developmental delays. Many of these “late talkers” will demonstrate language skills within the normal range by 3–5 years of age. Some may be at risk for developing spoken language and/or literacy difficulties. See ASHA’s Practice Portal page on Late Language Emergence for more information.

Some individuals with spoken language disorders are identified early. However, signs and symptoms of a spoken language disorder may also become apparent at the following times:

• through evaluation of metacognitive/metalinguistic ability (e.g., phonological awareness)
• when later-developing language domains (e.g., reading and writing) are emerging
• when children encounter the unique disciplinary language associated with certain academic subjects (e.g., humanities classes vs. science classes)
• through observation of emotional and/or behavioral difficulty

Below are common signs and symptoms among children with spoken language disorders. The signs and symptoms are grouped by domain and appear in descending order from basic to higher-order skills. Although these domains are listed separately, it is important to note that skills are not discrete and that there is an interactive relationship between domains.

Phonology

Phonological signs and symptoms include

• a delay in the acquisition of phonological skills, including errors similar to those of younger children without spoken language disorders but with greater variability in production at similar stages of phonological development;
• problems with early speech sounds affecting intelligibility, generally resolving over time;
• difficulty learning the speech sound system of language, resulting in poor repetition of single-syllable and multisyllabic nonwords; and
• limited phonological awareness (e.g., rhyming, sound/syllable deleting, segmenting, and blending).

Morphology and Syntax

Morphology and syntax signs and symptoms can include the following:

• a history of late acquisition of word combinations
• restricted mean length of utterance in morphemes for younger children (although developmental order of morpheme acquisition may be similar to that of children without spoken language disorders) and shorter utterances in words for school-age children and adolescents
• difficulty comprehending grammatical morphemes, particularly units of short duration (phonetically less salient)
• errors in English of omission occur more frequently than errors of misuse, although occurrence of both error types may be inconsistent.
• errors in morphological awareness (e.g., derivational morphemes, such as prefixes and suffixes, and inflectional morphology, such as plural, present progressive, and past tense markers)
• difficulty identifying and correcting grammatical errors
• problems comprehending and using complex syntactic sentences in narratives to convey information
• difficulty with curriculum-related expository discourse production and comprehension
• difficulty decoding and comprehending morphologically complex words that are common in various academic subjects
• errors in English occur most often on
• verbs (especially verb endings, auxiliary verbs, and past tense marking of regular and irregular forms);
• function words (e.g., articles and prepositions); and
• pronouns.
• error types differ within various English dialects.

Semantics

The semantic profile can include the following:

• a history of late acquisition of first words and word combinations
• a slower rate of vocabulary development than that of children without spoken language disorders (not attributed to second-language acquisition)
• delays in verb acquisition, particularly in languages in which verbs are highly inflected morphologically
• poor fast mapping (after a brief or single encounter) of a new word to its referent
• difficulty understanding new words, particularly action words or words that convey abstract meanings
• word-finding difficulties (the person may excessively use filler words such as “um” to take up time while searching for a word or formulating thoughts)
• slower confrontation naming that may reflect less rich and less elaborate semantic memory networks
• difficulty with listening comprehension, such as understanding questions and following directions
• problems comprehending and using synonyms and antonyms, multiple-meaning words, and figurative language (e.g., idioms, metaphors, proverbs, humor, poetic language)
• problems comprehending slang and acronyms used by same-age peers
• poor organization of narratives and expository discourse (which impacts the ability to convey the intended meaning)
• poor comprehension of narrative or expository text, particularly when it is necessary to draw inferences from literal content or when expository text is associated with different academic disciplines

Pragmatics

The pragmatic profile can include the following:

• difficulty initiating play with peers (may frequently play alone)
• difficulty understanding others’ thoughts and feelings
• perceived immaturity in relation to same-age peers
• difficulty expressing ideas, feelings, and personal experiences
• use of the same pragmatic functions as peers (but a less effective expression of them)
• difficulty initiating and sustaining conversations
• difficulty modifying a message based on the listener or when repairing communication breakdowns
• limited classroom discourse skills (e.g., language productivity and complexity, self-monitoring, turn-taking), depending on the context (e.g., curriculum-related or nonacademic peer interactions)
• difficulty with monitoring comprehension, including paraphrasing information or requesting clarification
• difficulty making relevant contributions to classroom discussions
• difficulty using language to sequence events of a story (narratives lack cohesion) a tendency to omit some story components
• difficulty keeping up with fast-paced peer interactions
• reluctance or avoidance of peer interactions

See ASHA’s Practice Portal page on Social Communication Disorder for more information about pragmatics.

Behavioral, Emotional, and Social Considerations

Individuals with spoken language disorders may experience social/emotional problems and/or show behaviors associated with language impairment. They are at higher risk for depression and anxiety than the general population (Conti-Ramsden & Botting, 2008). The impact of language disorders can result in misperceptions and misattributions of the child’s behavior (Cohen et al., 1993).

Children with spoken language disorders may show the following:

• exhibit behavioral difficulties, including hyperactivity and attentional difficulties (Dockrell et al., 2007)
• demonstrate behavioral reticence (withdrawal, wariness, shyness) that can affect initiation of close relationships in adolescence (Fujiki et al., 2004)
• have difficulty inferring emotional reactions of others (Ford & Milosky, 2003)
• have difficulty judging when it is appropriate to hide emotions/feelings (Brinton et al., 2007)
• have difficulty regulating emotions (e.g., monitoring, evaluating, and modifying emotional reactions; Fujiki et al., 2002)
• have poor social self-esteem (Marton et al., 2005)
• have difficulty forming and maintaining close social relationships—as adolescents, may be less emotionally engaged in their close relationships (Wadman et al., 2011)
• be at risk for bullying and other forms of abuse (Blood, 2014; Brownlie et al., 2007)

Although few people with spoken language disorders enter the criminal justice system, many people in the criminal justice system have spoken language disorders. Children and adolescents with spoken language disorders are overrepresented in juvenile justice populations (LaVigne & Van Rybroek, 2011; Snow, 2019).

Misperceptions of behaviors, misdiagnosis, and lack of proper supports might place the child at risk for becoming part of the “school-to-confinement pipeline” population. Zero-tolerance policies may enforce punishment without consideration of how language impairments and additional diagnoses impact a student’s behavior (Stanford, 2020). For youth involved in the juvenile justice system up to 21 years of age, 60%–64% were found to have a language disorder, with 50% being considered to have a moderate disorder and 10% a severe language disorder (Chow et al., 2022; Zupan et al., 2022).

See The ASHA Leader article, Casualties of Misunderstanding: Communication Disorders and Juvenile Injustice.

Spoken language disorders have a variety of causes. In some cases, the cause is clearly environmental such as traumatic brain injury or fetal alcohol syndrome. Sometimes, the cause is due to a single affected gene, such as Down syndrome or fragile X syndrome. Most cases are due to multiple affected genes, such as autism, intellectual disability, and developmental language disorder (DLD). Genes are expressed in an environment, so environmental risks such as premature birth, exposure to tobacco smoke, or poor nutrition will increase the risk of language disorder.

Researchers do not fully understand the etiology of DLD or specific language impairment. It is useful to consider the cause as an interaction of multiple, complex factors. DLD tends to run in families (Bishop et al., 1995; Tomblin, 1989), and multiple genetic factors contribute to the presence of DLD (see Mountford et al., 2022, for a review). For example, a genetic variation might lead to a difference in brain morphology or function that leads to a difference in cognitive processing (Reed, 2012). Research on DLD reveals causation at multiple levels:

• cognitive processing deficits (e.g., Ellis Weismer & Evans, 2002; Leonard et al., 2007; Miller et al., 2001)
• genetic variations (e.g., Rice, 2012, 2013)
• neurological differences, observed through brain imaging studies (e.g., Ellis Weismer et al., 2005; Galaburda, 1989; Hugdahl et al., 2004)

Speech-language pathologists (SLPs) play a critical role in the screening, assessment, diagnosis, and treatment of preschool and school-age children with spoken language disorders. The professional roles and activities in speech-language pathology include prevention and education, screening and assessment, and intervention and support. See ASHA’s Scope of Practice in Speech-Language Pathology (ASHA, 2016).

Appropriate roles for SLPs are as follows.

Education

• Provide information on prevention to individuals and groups known to be at risk for spoken language disorders—as well as to individuals working with those at risk.
• Provide information to parents, health care professionals, teachers, and other school staff about the characteristics of spoken language disorders to facilitate early identification.
• Educate other professionals on the needs of people with spoken language disorders and the role of SLPs in diagnosing and managing spoken language disorders, including what constitutes a language disorder versus a language difference.

Screening and Assessment

• Screen individuals for the presence of language and communication difficulties, and determine the need for further assessment and/or referral for other services.
• Recognize that students who have been identified as having a spoken language disorder have heightened risks for literacy problems.
• Conduct a comprehensive, culturally and linguistically appropriate assessment of language and communication.
• Gain sufficient knowledge of an individual’s cultural and linguistic background to distinguish disorder within dialect(s) and language(s).
• Understand potential situational bias, test-item bias in assessment, and examiner bias/effects.
• Diagnose the presence of spoken language disorders.
• Refer to other professionals to rule out other conditions, determine etiology, and facilitate access to comprehensive services.

Intervention and Support

• Develop treatment plans, provide treatment, document progress, and determine appropriate dismissal criteria.
• Use culturally responsive intervention techniques and materials.
• Counsel individuals with a spoken language disorder and their families regarding communication-related issues and provide education aimed at preventing further complications relating to spoken language disorders. See ASHA’s Practice Portal page on Counseling in Audiology and Speech-Language Pathology.
• Collaborate and consult with the person with a spoken language disorder, the family, care partners, and interprofessional teams to make decisions about the evaluation and management of spoken language disorders, facilitate program development, and/or provide expert testimony, as appropriate. See ASHA’s resources on interprofessional education/interprofessional practice (IPE/IPP); clinical education and supervision; collaboration and teaming; collaborating with interpreters, transliterators, and translators; and focusing care on individuals and their care partners.
• Remain informed of research in the area of spoken language disorders and help advance the knowledge base related to the nature and treatment of spoken language disorders.
• Advocate for individuals with spoken language disorders and their families at the local, state, and national levels.

As indicated in the ASHA Code of Ethics (ASHA, 2023), SLPs who serve this population should be specifically educated and appropriately trained to do so.

Screening

Screening of spoken language skills is conducted if a language disorder is suspected. Some school districts screen all children for a speech or language disorder to accelerate identification and intervention.

Screening does not result in a diagnosis but rather indicates the potential need for further audiologic, language, and/or speech sound assessment.

Screening typically includes the following:

• teacher and/or caregiver report regarding concerns about the child’s language skills
• hearing screening to rule out hearing loss as a possible contributing factor to language difficulties
• standardized screening assessments with adequate sensitivity and specificity, if appropriate
• informal measures, such as those designed by the clinician and tailored to the population being screened (e.g., preschool vs. school age/adolescence)
• articulation screening, if indicated

Many children who have experienced trauma pass language screening tests but may still experience language problems that require intervention (Ciolino et al., 2021). See ASHA’s resource on trauma-informed care.

Multi-Tiered System of Support (MTSS)

A multi-tiered system of support (MTSS) is a data-driven framework to support the academic, behavioral, emotional, and social success of all students in the general and special education settings (Center on Multi-Tiered System of Supports, n.d.). Essential components of the MTSS include universal screening, progress monitoring, data-based decision making, and a multi-level prevention system (Center on Multi-Tiered System of Supports, n.d.).

Response to intervention (RTI) is an example of a three-tiered multi-level prevention system [PDF]. Speech-language pathologists (SLPs) can have several roles in the RTI process to identify children with disabilities and to provide instruction to struggling students. Educators cannot use the RTI process to delay or deny an evaluation to determine if a student is eligible to receive special education and related services under the Individuals with Disabilities Education Act (IDEA; Office of Special Education and Rehabilitative Services, 2004).

See ASHA’s resource on RTI for more information about how SLPs can be part of the RTI process.

Comprehensive Assessment

If screening results indicate a need for further testing, then an SLP conducts a comprehensive and linguistically appropriate assessment. Assessment of language skills should be culturally relevant and functional and should involve the collaborative efforts of families/caregivers, classroom teachers, SLPs, special educators, cultural brokers, interpreters, and other professionals, as needed. See Assessment and Evaluation of Speech-Language Disorders in Schools. See also ASHA’s Person-Centered Focus on Function: Language Disorder [PDF] for an example of assessment data consistent with the World Health Organization’s International Classification of Functioning, Disability and Health.

Assessment typically includes the following, with consideration made for the child’s age and linguistic development.

Case History

The SLP gathers relevant case history, including the following:

• birth, medical, and developmental history
• family history of cognitive, speech, language, reading, or academic difficulties
• family’s concerns about the child’s language (and speech)
• child’s perspectives of strengths and weaknesses
• languages and/or dialects used, including
• age of introduction of additional language(s), as appropriate
• circumstances in which each language is used
• parent/caregiver perspective on how the child acquired language relative to siblings, as appropriate
• parent, teacher, and child self-report measures of communication and behaviors, based on reason for referral
• teachers’ concerns regarding the impact of the child’s language difficulties on classroom functioning
• classroom- and curriculum-based assessment data

Oral Mechanism Examination

The oral mechanism examination evaluates the structure and function of the speech mechanism to assess whether the system is enough for speech production. This examination typically includes an assessment of

• dental occlusion and specific tooth deviations;
• structures of the oral cavity (e.g., hard and soft palate, lingual frenulum); and
• function (strength and range of motion) of the lips, jaw, tongue, and velum.

Hearing Screening

A hearing screening is conducted during the comprehensive assessment if one was not completed during the screening.

A hearing screening typically includes

• an otoscopic inspection of the ear canal and tympanic membrane,
• pure-tone audiometry, and
• immittance testing to assess middle ear function.

Speech and Language Evaluation

Spoken language testing may include the following domains:

• phonology, including phonological awareness
• semantics
• morphology
• syntax
• pragmatics, including discourse-level language skills (conversation, narrative, expository)

Assessment is accomplished using a variety of measures and activities, including both formal and informal assessment tools. Depending on the child’s cultural and linguistic background and communication profile, these tools may or may not be standardized and may be quantitative or qualitative measures. See ASHA’s resource on assessment tools, techniques, and data sources.

At this time, there are few standardized assessments developed in the United States for individuals who use additional languages besides English or dialects of English outside of General American English. It is essential to consider the language(s) and dialect(s) used by the child before selecting any standardized assessment. Standard scores are not reported when an assessment has been translated or used with a population it was not intended for; however, a narrative description of performance can be provided.

Dynamic assessment is a language assessment method (test–teach–retest) that helps identify the person’s current skills as well as their learning potential. Individuals able to make changes or modifications to their language by learning a skill are likely to have language differences, whereas those unable to make changes to their language by learning a skill are more likely to have a language disorder. Dynamic assessment can be used in conjunction with other assessment tools to guide clinical interpretations and recommendations.

See ASHA’s resource on dynamic assessment and ASHA’s Practice Portal pages on Cultural Responsiveness and Multilingual Service Delivery in Audiology and Speech-Language Pathology. See also the Spoken Language Disorders section of the Cultural and Linguistic Diversity (CLD) Evidence Map.

Cognition

Assessing cognitive abilities, such as executive function, helps identify the individual’s strengths and weaknesses and facilitates the development of a treatment plan. Cognitive abilities are often comprehensively evaluated by other professionals, such as psychologists. Given the interaction between cognitive processes and language abilities, SLPs and those who assess broad cognitive skills collaborate as much as possible on administering and interpreting evaluation findings. See the Assessment section of ASHA’s Practice Portal page on Executive Function Deficits.

Literacy

A literacy (reading and writing) assessment is included in the comprehensive assessment for language disorders because of the well-established connection between spoken and written language. Components of a literacy assessment will vary, depending on the child’s age and stage of language development, and can include preliteracy, early literacy, and advanced literacy skills. See the Assessment section of ASHA’s Practice Portal page on Written Language Disorders.

Speech

A speech sound assessment may also be included, given that speech sound errors can be a result of a phonological disorder, an articulation disorder, or a combined phonological–articulation disorder. See the Assessment section of ASHA’s Practice Portal page on Speech Sound Disorders: Articulation and Phonology.

If appropriate, an assessment of an alternative or augmentative form of communication may be conducted. See ASHA’s Practice Portal page on Augmentative and Alternative Communication (AAC).

A comprehensive assessment may result in the following:

• the determination of a cultural and linguistic difference only, which would not require further evaluation or intervention
• the diagnosis of a spoken language disorder (receptive language disorder only, expressive language disorder only, or expressive–receptive mixed)
• a description of the characteristics and severity of the disorder
• a determination of performance variability as a function of communicative situations/contexts
• the identification of literacy problems
• the diagnosis of a speech sound disorder
• the identification of possible hearing problems
• recommendations for intervention and support
• a referral to other professionals, as needed.

Considerations For Diagnosis of Spoken Language Disorder

Early Identification

Not all children with early language delay (late talkers) have significant language problems when they reach school age (Paul, 1989, 1996; Rescorla, 2002). This makes it difficult to diagnose a language disorder before the age of about 3 years (Leonard, 2014). However, given the risk that language disorders pose, it is essential to assess a child’s language skills early and to monitor these skills periodically at critical educational stages (e.g., preschool; kindergarten, second grade, and third grade; early middle school; and high school). See ASHA’s Practice Portal page on Late Language Emergence.

It is especially important to periodically monitor and assess language skills if multiple risk factors are present, such as a family history of language problems, chronic otitis media, cognitive delay, social communication difficulties, and environmental risks (Paradise et al., 2000; Paul, 1996; Paul et al., 2018).

Determining Eligibility For Special Education services

In the school setting, children with spoken language disorders who meet the eligibility criteria under IDEA receive special education services through an individualized education program under the primary or secondary disability category “speech or language impairment” (IDEA, 2004). Younger children may qualify under the category “developmental delay,” whereas older children often qualify under “specific learning disability.” Eligibility criteria include a disability that adversely affects educational performance, which is not limited to academic performance. See ASHA’s resource on eligibility and dismissal in schools.

Students who have a speech or language impairment, but do not qualify for special education services under IDEA, may be eligible for a 504 plan, under Section 504 of the Rehabilitation Act of 1973. For more information, see ASHA’s Practice Portal page on Documentation in Schools and ASHA’s resource on individualized education programs (IEPs), individualized family service plans (IFSPs), and Section 504 plans.

See also The ASHA Leader article on the IDEA guidance about the eligibility of developmental language disorders under IDEA.

Changing Nature of Spoken Language Disorder

Children with spoken language disorders can show different patterns of strengths and weaknesses across listening, speaking, reading, and writing, and these patterns may vary over time. In some cases, the language skills of children with spoken language disorders can seem similar to those of children without spoken language disorders.

However, as language demands increase, difficulties may resurface in one or more language domains, especially in written language. For example, children may no longer produce verb errors in conversations but may make these errors in written assignments. This phenomenon is referred to as illusory recovery (Scarborough & Dobrich, 1990). Although children may gain new vocabulary or improve their use of grammatical forms following language intervention, they typically do not catch up to their peers. Their rate of language growth may slow or level off when they reach early adolescence, resulting in language levels below those expected for their age (Rice, 2013). Language gaps between children with spoken language disorders and their peers without spoken language disorders may widen over time, such as with vocabulary (Rice & Hoffmann, 2015).

For this reason, clinicians use valid and reliable standardized assessments with normative data—in addition to other data sources (e.g., informal measures, benchmarking, progress reports)—when evaluating the language skills of children with spoken language disorders over time. Periodic monitoring of children who have been dismissed from services is also crucial.

Cultural and Linguistic Considerations

Clinicians may face unique challenges when identifying spoken language disorders in children who are multilingual, use a language they do not use, or speak a nonmainstream dialect of English. Diagnosing spoken language disorders requires the following skills:

• awareness of multilingual language acquisition (simultaneous and sequential)
• cultural and linguistic information about named languages that the child uses
• familiarity with the patterns of the child’s dialect in their named languages

For children who speak a dialect of English, such as Appalachian English or African American English, clinicians consider the influence of dialect patterns on assessment measures—which are typically based on Mainstream American English or General American English dialect. Standard score interpretations are not valid if the norming sample of an assessment is not representative of the child being assessed or when using accommodations or modifications that are not specified in the test manual. See IDEA Part B: Culturally and Linguistically Diverse Students.

Rather than a strictly dialect versus disorder framework, a disorder within dialect framework keeps the nature and prevalence of childhood language disorders across dialects at the forefront when considering screening, assessment, and treatment planning as well as when providing education about the services that clinicians provide (Oetting et al., 2016).

Multilingualism is not a cause of speech or language disorders. In multilingual children, language dominance may vary across domains of language, and competence may vary across named languages. For example, children may exhibit receptive language dominance in one language and expressive language dominance in another. Dominance may also shift over time relative to environmental linguistic demands. For multilingual children who have language impairment, typical processes of multilingualism, such as code-mixing, will be present in their speech (Gutiérrez-Clellen et al., 2009).

Signs of expressive language difficulties will be present in all languages and dialects a child uses. Morphosyntactic delays (Castilla-Earls et al., 2021; V. P. Smith et al., 2021), decreased vocabulary and semantic knowledge (Kan et al., 2020), and reduced lexical diversity in narratives (Kapantzoglou et al., 2017) can be present in the expressive language of multilingual children with developmental language disorder.

There are some learning behaviors that a student might exhibit that could represent a language difference instead of a potential learning disability. By determining the root of each student’s difficulties using multiple sources of converging evidence, clinicians are better equipped to make diagnostic decisions (Castilla-Earls et al., 2020). See Tool #2 in the U.S. Department of Education’s English Learner Toolkit, Chapter 6, for more information about English language learners across language domains and content areas.

For assistance with diagnosing spoken language disorders in children who use additional dialects and languages, see ASHA’s Practice Portal pages on Cultural Responsiveness and Multilingual Service Delivery in Audiology and Speech-Language Pathology as well as ASHA’s resource on phonemic inventories and cultural and linguistic information across languages. See also the Spoken Language Disorders section of the Cultural and Linguistic Diversity (CLD) Evidence Map.

Disproportionality of Identification

A disproportionate number of children who speak English as an additional language or minoritized dialects of the English language have been over- or under-identified in the school setting as having a speech-language impairment (Robinson & Norton, 2019). For example, children from minoritized backgrounds who may speak non-Mainstream American English dialects are less likely to receive needed services than similar Mainstream American English– or General American English–speaking peers (Morgan et al., 2015, 2017). This disproportionality may be due to various factors, such as students classified in other IDEA disability categories (e.g., specific learning disability, emotional disturbance), cultural differences, and standardized tests based on General American English (Robinson & Norton, 2019).

Non-normed (criterion) measures, ethnographic interviewing, and dynamic assessment procedures are fundamental to determining how someone’s linguistic system influences their current language. Use of an accent or a dialect that is unfamiliar to the listener is not an indication of a spoken language disorder. Children who have a language difference, without a disability, are not eligible for special education services.

See ASHA’s Practice Portal pages on Cultural Responsiveness and Multilingual Service Delivery in Audiology and Speech-Language Pathology.

Cognitive Referencing

Cognitive referencing compares intelligence quotient scores and language scores as a factor to determine a child’s eligibility for speech and language intervention. This practice assumes that a language delay warrants intervention only when language skill development lags behind cognitive skill development. ASHA does not advise using cognitive referencing as one of the criteria for admission into or discharge from speech and language services (ASHA, 2004a).

The National Joint Committee for the Communication Needs of Persons With Severe Disabilities (2002) identified several concerns about using cognitive referencing, including the following:

• The relationship between language and cognition is complex and changes over time.
• Tests of cognitive and linguistic ability often measure the same fundamental skills.
• Assessments that are typically used for deriving cognitive and language profiles often result in sizable variation in discrepancy determinations.
• Children with commensurate impaired cognitive and language skills would not receive the diagnosis of language impairment or the associated language services that they need. Children with commensurate cognitive and language impairments can still make positive gains with language intervention (Snell et al., 2010).
• These issues with cognitive referencing are compounded by the fact that many standardized tests are culturally biased (e.g., the normative sample is not representative of all children from varied ethnic, racial, and socioeconomic backgrounds), resulting in inaccurate score interpretations.

Widely using presumptive criteria—including discrepancies between cognitive abilities and communication functioning, chronological age, or diagnosis—to determine eligibility for services is not consistent with the law and IDEA regulations. See ASHA’s resource on cognitive referencing for more information.

College- and Career-Readiness State Standards

College- and career-readiness state standards, such as the Common Core State Standards, are rigorous curriculum learning standards that most states have implemented. College- and career-readiness standards align with the knowledge and skills necessary to prepare students to enter college and the workforce.

Language skills are addressed across subject areas, and the English Language Arts standards focus on the use of language for communication and academic success. Students who have language disorders may require specialized instruction and support to access the curriculum standards.

English Language Proficiency and/or English Language Development (ELP/D) Standards

ELP/D standards are specifically developed for students learning English and define progressive levels of English language competence. Reading and language arts standards are not the same as ELP/D standards. Two kinds of English language skills are taught and tested for school success:

1. social and intercultural competence for the classroom
2. academic language needed to access content areas (i.e., English language arts, mathematics, science, social studies)

ELP/D standards act as a starting point for identifying the language that multilingual learners must develop to successfully access content in and beyond educational settings. Clinicians can use this information to plan linguistically appropriate individualized education program goals for multilingual learners with spoken language disorders.

The goals of language intervention are to stimulate overall language development and to teach language skills in an integrated way and in context—with the aim of enhancing everyday communication and ensuring access to academic content. Goals are frequently selected with consideration for developmental appropriateness and the potential for improving the effectiveness of communication and academic and social success. See ASHA’s Person-Centered Focus on Function: Language Disorder [PDF] for an example of functional goals consistent with the World Health Organization’s International Classification of Functioning, Disability and Health.

Spoken language disorders are heterogeneous in nature, and the severity of the disorder can vary. Each individual with language difficulties has a unique profile, based on their current abilities with language, hearing, cognition, and speech production. Many individuals with spoken language disorders can benefit from interventions that are family-centered. Family-centered care views speech and language services as a collaboration between the clinician, the client, and their family. See ASHA’s resource on Focusing Care on Individuals and Their Care Partners.

Along with person- and family-centered care, individuals with spoken language disorders may also benefit from a strengths-based approach that affirms neurodiversity—including identifying the individual’s strengths, respecting the use of identity-first language, presuming competence, focusing on environmental supports, and allowing the individual to make their own choices (Donaldson et al., 2017).

In addition to considering the unique profile of strengths and needs, the clinician who uses a strengths-based approach considers the language(s) and dialect(s) used during intervention. For example, if the child’s heritage language and the language of instruction differ from one another, then the clinician might incorporate both languages into their treatment approach (Hamilton et al., 2018).

As indicated in the ASHA Code of Ethics (ASHA, 2023), audiologists and speech-language pathologists (SLPs) are obligated to provide culturally and linguistically appropriate services, regardless of the clinician’s personal culture (e.g., race, ethnicity, religion, sexual orientation, gender identity), practice setting, or caseload demographics. Multilingual clinicians who have the necessary clinical expertise to treat the individual may not always be available. When a language-matched clinician is not available, clinicians then collaborate with an interpreter to ensure that the individual receives clinically appropriate services. See ASHA’s Practice Portal pages on Multilingual Service Delivery in Audiology and Speech-Language Pathology and Collaborating With Interpreters, Transliterators, and Translators. See also the Spoken Language Disorders section of the Cultural and Linguistic Diversity (CLD) Evidence Map.

Treatment Targets

Roth and Worthington (2018) summarize steps in the selection and programming of treatment targets and provide sample case profiles for early intervention through adolescence. They also identify a number of basic principles of effective intervention regardless of client age or disorder—including the four principles listed below.

1. To the maximum extent possible, teach strategies for promoting communication rather than teaching isolated behaviors.
2. Provide intervention that is dynamic in nature and that includes ongoing assessment of the child’s progress in relation to their goals, modifying them as necessary.
3. Provide intervention that is individualized, based on the nature of a child’s needs, the languages they used, and their individual learning style.
4. Tailor the treatment goals to promote a child’s knowledge one step beyond the current level.

The sections below outline the intervention targets for various age ranges. Older people with severe language impairments may be functioning at developing language levels. Rather than being based on developmental sequences, interventions for these people may be more functional in nature, focusing on building independence in everyday settings.

Intervention for Preschoolers (Ages 3–5 years)

Language develops at a rapid pace in preschool children without spoken language disorders. Their vocabularies are growing, and they are beginning to master basic sentence structures. For children with language difficulties, this process may be delayed. Areas that might be targeted for intervention typically include the following.

Phonology

• Improving intelligibility, if a speech sound disorder is indicated (particularly if impairments result in frustration and/or mask problems in semantics and syntax), including
• increasing the consonant repertoire,
• improving the accuracy of sound production, and
• decreasing use of phonological processes.
• Enhancing phonological awareness skills, such as the following three examples:
• rhyming
• blending and segmenting spoken words at the following levels:
• sentence and phrase level (one sentence with three words: “The happy boy”)
• syllable level (two syllables in “pancake”: “pan” and “cake”),
• onset and rhyme level (two onsets: “p” and “c”; two rhymes: “an” and “ake”)
• phoneme level (three phonemes: “p” + “a” + “n”)
• deleting and substituting of syllables and phonemes in spoken words

Semantics

• Increasing the size of vocabulary, including
• verbs;
• pronouns;
• conjunctions;
• basic concept vocabulary (e.g., colors); and
• academic vocabulary (i.e., cross-disciplinary or discipline-specific words used in the school context).
• Increasing understanding and use of a wider range of semantic relationships (e.g., agent–action, agent–object, possessor–possession, attribute–entity, recurrence).
• Improving the semantic depth or richness of familiar words.

Morphology and Syntax

• Facilitating the acquisition and use of age-appropriate morphemes within the child’s dialect—in particular, auxiliary verbs, articles, and pronouns.
• Increasing sentence length and complexity.
• Increasing use of varied sentence types.

Pragmatics

• Increasing language flexibility for various contexts.
• Using imaginative play activities to practice newly acquired language skills.
• Improving conversational skills, including
• initiating and maintaining communication;
• turn-taking, topic maintenance, and topic shifts; and
• requesting and making conversational repairs.
• Developing narrative skills.

See ASHA’s Practice Portal page on Social Communication Disorder for more information about pragmatics.

Literacy

• Building emergent literacy skills, including
• print awareness,
• book awareness,
• understanding simple story structure,
• letter knowledge, and
• matching speech to print.

See the Treatment section of ASHA’s Practice Portal page on Written Language Disorders.

Intervention For Elementary School Children (Ages 5–10 years)

The focus of language intervention for elementary school children with language difficulties is to help the child acquire the language skills needed to learn and succeed in a classroom environment. Interventions are curriculum-based, addressing language needs within the context of the curriculum.

Areas targeted for this population typically are as follows.

Phonology

• Enhancing phonological awareness skills.
• Eliminating any residual phonological processes.

Semantics

• Improving knowledge of vocabulary, including knowledge of curriculum-related vocabulary.
• Improving depth of vocabulary understanding and use, including
• subtle differences in meaning,
• changes in meaning with context,
• abstract vocabulary, and
• figures of speech.
• Recognizing ambiguities in language (e.g., words with multiple meanings and ambiguous sentence structures).
• Monitoring comprehension by requesting clarification.
• Paraphrasing information.

Morphology and Syntax

• Increasing the use of more advanced morphology (e.g., “monster/monstrous,” “medicine/medical,” “initiate/initiative”).
• Increasing the ability to analyze morphologically complex words (e.g., prefixes, suffixes).
• Improving morphosyntactic skills (e.g., use of morphemes in simple and complex clauses, declarative statements vs. questions, relative clauses).
• Improving the ability to understand and formulate more complex sentence structures (e.g., compound sentences; complex sentences containing dependent clauses).
• Judging the correctness of grammar and morphological word forms and being able to correct errors.

Pragmatics

• Using language in various contexts to convey politeness, persuasiveness, and clarification.
• Increasing discourse-level knowledge and skills, including
• academic discourse,
• social interaction discourse,
• narrative discourse,
• expository discourse, and
• use of cohesive devices in discourse.
• Improving the ability to make relevant contributions to classroom discussions.
• Improving the ability to repair conversational breakdowns.
• Learning what to say and what not to say.
• Learning when to talk and when not to talk.

Literacy

• Improving word recognition and decoding.
• Improving reading fluency.
• Improving reading comprehension.
• Improving narrative and expository writing.

See the Treatment section of ASHA’s Practice Portal page on Written Language Disorders.

Metalinguistics and Metacognition (critical for developing higher-level language skills)

• Improving awareness and application of rules and principles governing various language forms.
• Improving awareness of others as listeners.
• Improving the ability to plan, monitor one’s performance, and evaluate/modify one’s work.

Intervention For Adolescent Students (Ages 11 years Through High School)

Instructional strategies are often used with older students. This approach focuses on teaching rules, techniques, and principles to help acquire and use information across a broad range of situations and settings. Curriculum demands increase as students enter their adolescent years, and children with language disabilities may have difficulty accessing the higher-level curriculum. It may not be possible to close the gap between skill level and grade level. At this point, interventions tend to focus on teaching ways to compensate for language challenges. Student involvement helps foster a feeling of collaboration and responsibility for achieving goals and learning how to self-advocate in the classroom. Adolescent students may also benefit from a strengths-based approach that leverages the student’s assets and focuses on creating environmental supports (Murza, 2021).

Enhancing metalinguistic and metacognitive skills is fundamental to learning new strategies. The emphasis is on how to learn rather than on what to learn. Classroom assignments are often used to teach strategies for learning academic content. Some instructional strategies are discipline-specific, and others are generalizable across disciplines (Faggella-Luby & Deshler, 2008).

Examples of strategies are as follows:

• using context to deduce meaning, make inferences, and identify main ideas
• deciphering morphologically complex words associated with different disciplines (e.g., history, literature, chemistry, algebra)
• creating checklists and graphic organizers to plan assignments (e.g., book reports, presentations, research papers)
• using spell check and grammar check to edit written work completed in electronic format
• using digital technologies (e.g., Internet, collaboration sites) to access and evaluate information, share and collaborate with classmates, produce shared products, and so forth

Not all language intervention approaches for adolescents focus on teaching strategies to students. Adolescents can also benefit from direct vocabulary instruction (Crosson et al., 2019; Elleman et al., 2019; Lowe et al., 2019; McGregor et al., 2021). Although it may not be possible to close the vocabulary gap between individuals with and without spoken language disorders, clinicians can carefully select words for direct instruction. This may include academic words that occur across multiple subjects (e.g., “summarize,” “describe”) or discipline-specific words that are crucial for understanding academic material (e.g., “molecule,” “archaeology”; Elleman et al., 2019; Gray & Yang, 2015).

Clinicians combine teaching strategies and providing direct instruction to best support adolescents with spoken language disorders (Elleman et al., 2019). Also see the Treatment section of the Written Language Disorders Practice Portal page.

Postsecondary Transition Planning

Children and adolescents with spoken language disorders may still need support as they move into postsecondary education and vocational settings. When compared to peers without spoken language disorders, fewer students with spoken language disorders complete high school or receive an undergraduate degree (Johnson et al., 2010). Many young adults with specific language impairment who pursue education after high school seek vocational rather than academic qualifications (Conti-Ramsden & Durkin, 2012).

The data on educational and vocational outcomes for individuals with speech and language disorders highlight the need for continued support to facilitate a successful transition to young adulthood. SLPs are involved in transition planning in high school and may be involved, to varying degrees, in other support services after high school.

Academic counseling includes a discussion about requirements for admission to postsecondary schools and the difference between services provided in K–12 special education programs and postsecondary disability support services. Students must disclose their disability and provide current documentation to access services in postsecondary settings. They need to be aware that the supports they can receive differ in postsecondary settings from those provided in K–12 settings.

The Americans with Disabilities Act and Section 504 of the Rehabilitation Act of 1973 [PDF] provide protections for students with disabilities transitioning to postsecondary education and work settings. These laws ensure that programs and employment environments are accessible and provide aids and services necessary for effective communication in these settings.

See ASHA’s resource on postsecondary transition planning for more information about the transition planning process and services.

Treatment Modes/Modalities

Treatment modes and modalities are technologies or other support systems that the SLP can use in conjunction with, or during the implementation of, various treatments. Several treatment modes and modalities are described below. When selecting a mode or modality, the SLP considers the intervention goal and the individual’s developmental stage. For example, a mode or modality that is appropriate for an individual who is at the emerging-language stage may not be appropriate for an individual who is at the prelinguistic stage. See ASHA’s Practice Portal page on Telepractice for more information about providing services via telepractice. The list below is not exhaustive, and inclusion does not imply endorsement from ASHA.

Augmentative and Alternative Communication (AAC)

An AAC system is an integrated group of components used to enhance communication. Individuals with spoken language disorders can use an AAC system as their main communication system or to supplement their spoken verbal communication. AAC uses the following techniques and tools to help the individual express thoughts, ideas, wants, needs, and feelings:

• picture communication systems
• line drawings or photographs
• video clips
• speech-generating devices
• tangible objects
• manual signs
• gestures
• finger spelling

For more information about AAC, see ASHA’s Practice Portal page on Augmentative and Alternative Communication (AAC).

Online Instruction

Online instruction involves the use of computer technology (e.g., iPads) and/or computerized programs (e.g., apps) for teaching language skills, including vocabulary, social skills, social understanding, and social problem solving (see, e.g., Khowaja & Salim, 2013; Weng et al., 2014). See the Service Delivery Options section below and ASHA’s Telepractice Practice Portal page for information about providing services via telepractice.

Video-Based Instruction

Video-based instruction (also called “video modeling”) is an observational mode of teaching that uses video recordings to provide a model of the target behavior or skill. The individual observes and then imitates video recordings of desired behaviors. Video modeling procedures can be implemented in three ways: (a) using a video of the behavior to be targeted with another person as a model, (b) using a video of the behavior to be targeted without a model (usually called “point-of-view video modeling”), or (c) using videos of the learner as a model (known as “self-modeling”). In all cases, the SLP works with the learner to provide practice and feedback. As recording devices become more portable and easier to use, video-based techniques are more frequently being used in treatment (see, e.g., Wilson, 2013).

Treatment Options

See the Treatment section of the Spoken Language Disorders Evidence Map for pertinent scientific evidence, expert opinion, and client/patient perspective.

Interventions can vary along a continuum of naturalness (Fey, 1986; Paul et al., 2018), ranging from drill-based activities in a therapy room to activities that model everyday activities in naturalistic settings. SLPs determine which methods and strategies are effective for a particular student by taking into consideration the individual’s language profile, the severity of the language disorder, factors related to language functioning (e.g., hearing impairment and cognitive functioning), cultural background and values, learning style, and communication needs. SLPs might combine these treatment options with a strengths-based framework for an inclusive approach to intervention. For older children and adolescents, this includes identifying and leveraging the student’s strengths and interests, promoting the student’s self-determined goals, and focusing on the environmental supports that facilitate the student’s success (Donaldson et al., 2017).

Below are brief descriptions of general and specific treatments for addressing language disorders. Treatment options are organized into broader categories, but intervention approaches do not always fit neatly into one category.

Several of the approaches listed below are most often associated with treatment for social communication disorder and autism. These approaches are also used with a broader population of children with language disorders. This list is not exhaustive, and the inclusion of any specific treatment approach does not imply endorsement from ASHA.

Language Interventions

Language interventions are designed to target specific language skills (e.g., phonology, semantics, syntax, morphology) or broader language and communication skills (e.g., verbal expression, narrative production, and social communication).

Language intervention approaches can include the following:

• Clinician-oriented—The clinician selects the goals and the treatment setting and determines the stimuli to be used and the type and schedule of reinforcement. These approaches use operant procedures and are often used to teach language form (e.g., syntax and morphology).
• Child-oriented—The clinician uses indirect language stimulation techniques and follows the child’s lead in natural, everyday settings and activities to stimulate language growth. These approaches are typically used with young children but can be modified for use with older children. Examples include the following:
  • Expansions—The child’s utterance is repeated in the clinician’s response, and the clinician adds grammatical and semantic detail (see Cleave et al., 2015, for a review on expansions and recasts).
  • Recasts—In this type of expansion, the adult repeats the child’s utterance but changes the form of the utterance (e.g., sentence to a question, active to passive voice; Cleave et al., 2015).
  • Buildups and breakdowns—The child’s utterance is first expanded (“buildup”), then is broken down into grammatical components (“breakdown”), and then is built up again to its expanded form.
• Hybrid—The clinician develops activities that are very natural but, at the same time, allow opportunities for the child’s spontaneous use of utterances containing the targeted language forms. Examples include the following:
  • Focused stimulation—The clinician produces a high density of the child’s target forms in meaningful and functional contexts; these contexts are designed to motivate target production by the child, although the child is at no time asked to respond (Alt et al., 2020; Fey et al.,1993; Girolametto et al., 1996).
  • Vertical structuring and expansion—The clinician presents a stimulus (e.g., a picture depicting a semantic relationship), asks the child to respond to the stimulus (e.g., “What is this?” “What’s happening?”), and then expands the child’s response into a well-formed sentence.

Narrative Interventions

Narrative interventions focus on improving a child’s storytelling ability and can provide a naturalistic means of targeting specific language difficulties. See Petersen (2011) and Pico et al. (2021) for systematic reviews of narrative interventions.

Narrative interventions target

• the ability to provide context for the listener,
• the use of narrative structures (story grammars) to organize events, and
• the use of microstructure (e.g., syntactic complexity, temporal and causal conjunctions, coordinating conjunctions, elaborated phrases, and adverbs) to enhance the clarity of the narrative.

Caregiver-Mediated or Caregiver-Implemented Intervention

Caregiver-mediated or caregiver-implemented intervention consists of parents’ use of direct, individualized intervention practices with their child to increase positive learning opportunities and acquisition of skills. For language intervention, caregivers may receive training and support from an SLP (see Roberts et al., 2019, for a detailed review). Caregiver-mediated or caregiver-implemented intervention is most often used with young children.

More Than Words®—a Hanen Program®—is one example of a caregiver-mediated intervention. It offers a parent-directed approach focusing on day-to-day life, taking advantage of everyday activities to help the child improve communication and social skills (Sussman, 1999). This program is typically used for early language intervention with young children with autism. Mettler et al. (2023) provided another example of a caregiver-implemented language intervention, which involved trained caregivers applying focused stimulation techniques to support vocabulary development.

Interactive Reading Interventions

Shared interactive book reading interventions, including read-aloud and dialogic reading, involve a trained caregiver or clinician reading a book to a child—or group of children—using different techniques to engage the child in the text (What Works Clearinghouse, 2015). Techniques may include the following:

• making predictions
• giving explanations about specific words or pictures
• asking open-ended questions or wh-questions about the story and characters
• modeling print and book awareness as well as critical thinking skills (e.g., relating the story’s topic to a real-life experience)

Shared book reading aims to support language development, emergent reading, and listening comprehension skills. The trained adult can implement this intervention in many settings (e.g., home, classroom, community) and from any socioeconomic background (Noble et al., 2020).

Peer-Mediated or Peer-Implemented Intervention

Peer-mediated or peer-implemented intervention incorporates peers, including siblings without language disorders, as communication partners for children with language disorders to provide effective role models and boost communication competence. Peers without spoken language disorders are taught strategies to facilitate play and social interactions; interventions are commonly carried out in inclusive settings where play with peers without spoken language disorders naturally occurs (e.g., preschool setting).

Relationship-Based Intervention

Relationship-based practices in early intervention are aimed at supporting parent–child relationships. DIR/Floortime® is one example of a relationship-based intervention. This model promotes development by encouraging children to interact with parents and others through play. It focuses on following the child’s lead; challenging the child to be creative and spontaneous; and involving the child’s senses, motor skills, and emotions (Greenspan et al., 1998).

Social Communication Intervention

Social communication interventions are designed to increase social skills and promote socially appropriate behaviors and communication, using story-based intervention, scripts, social group settings, and other platforms to teach peer interaction skills. See ASHA’s Practice Portal page on Social Communication Disorder.

Behavioral Interventions and Techniques

Behavioral interventions and techniques aim to teach target skills using the basic principles of behavior change. These methods are based on behavioral/operant principles of learning; they involve examining the antecedents that elicit a certain behavior, along with the consequences that follow that behavior, and then making adjustments in this chain to increase desired behaviors and/or decrease inappropriate ones. Behavioral interventions range from one-to-one, discrete trial instruction to naturalistic approaches.

Discrete trial training (DTT)—a one-on-one instructional approach using behavioral methods to teach skills in small, incremental steps in a systematic, controlled fashion. The teaching opportunity is a discrete trial consisting of an antecedent (such as an instruction from the teacher), a response from the learner, and a consequence or feedback regarding the response. DTT is most often used for skills that (a) learners are not initiating on their own; (b) have a clear, correct procedure; and (c) can be taught in a one-to-one setting.

Functional communication training (FCT)—a behavioral intervention program that combines the assessment of the communicative functions of maladaptive behavior with the use of applied behavior analysis procedures to teach alternative responses. Problem behaviors can be eliminated through extinction and replaced with alternate, more appropriate ways of communicating needs or wants. FCT can be used with children with autism across a range of ages and regardless of cognitive level or expressive communication abilities (Carr & Durand, 1985).

Incidental teaching—a teaching technique that uses behavioral procedures. The clinician provides naturally occurring teaching opportunities that are based on the child’s interests. The clinician follows the child’s lead and reinforces communication attempts as these attempts get closer to the desired communication behavior (McGee et al., 1999).

Milieu therapy—a range of methods (including incidental teaching) that are integrated into a child’s natural environment. Milieu therapy includes training in everyday environments and during activities that take place throughout the day rather than only at “therapy time” (Kaiser et al., 1992).

Pivotal response treatment (PRT)—a play-based, child-initiated behavioral treatment. Formerly referred to as the “natural language paradigm,” PRT’s goals are to

• teach speech sounds, first words, and language;
• decrease disruptive behaviors; and
• increase social, communication, and academic skills.

Rather than target specific behaviors, PRT targets pivotal areas of development (response to multiple cues, motivation, self-regulation, initiation of social interactions, and empathy) that are central to a wide range of skills (Koegel & Koegel, 2019). PRT emphasizes natural reinforcement (e.g., the child is rewarded with an item when they make a meaningful attempt to request that item).

Treatments Not Recommended

Several treatment options and approaches lack scientific evidence of validity and are not endorsed by ASHA. Below are brief descriptions of these treatments, along with ASHA’s position on each. Click on the hyperlinks provided to read ASHA’s full position statements.

Auditory Integration Training

Auditory integration training (AIT; Bérard, 1993), also known as “the Bérard method,” is a type of sensory integration treatment that involves exercising the middle ear muscles and auditory nervous system. AIT claims to treat a variety of auditory and nonauditory disorders, including auditory processing problems, dyslexia, learning disabilities, attention-deficit disorders, and autism.

According to ASHA’s position statement, Auditory Integration Training: “The 2002 ASHA Work Group on AIT, after reviewing empirical research in the area to date, concludes that AIT has not met scientific standards for efficacy that would justify its practice by audiologists and speech-language pathologists” (ASHA, 2004b, para. 1).

Facilitated Communication

Facilitated communication (FC)—also referred to as “assisted typing,” “facilitated communication training,” and “supported typing”—is a technique that involves a “facilitator” using physical support (e.g., supporting the hand) to “assist” a nonspeaking person with a disability to point to letters, pictures, or objects on a keyboard or on a communication board.

According to ASHA’s position statement, Facilitated Communication, "It is the position of the American Speech-Language-Hearing Association (ASHA) that Facilitated Communication (FC) is a discredited technique that should not be used. There is no scientific evidence of the validity of FC, and there is extensive scientific evidence—produced over several decades and across several countries—that messages are authored by the ‘facilitator’ rather than the person with a disability. Furthermore, there is extensive evidence of harms related to the use of FC. Information obtained through the use of FC should not be considered as the communication of the person with a disability” (ASHA, 2018a, para. 1).

Rapid Prompting Method

The rapid prompting method (RPM)—also known as Soma® RPM, “informative pointing,” “letterboarding,” and “spelling to communicate”—involves an instructor prompting the person who is nonspeaking to point to letters on a letter board to spell out words.

According to ASHA’s position statement, Rapid Prompting Method, “It is the position of the American Speech-Language-Hearing Association (ASHA) that use of the Rapid Prompting Method (RPM) is not recommended because of prompt dependency and the lack of scientific validity. Furthermore, information obtained through the use of RPM should not be assumed to be the communication of the person with a disability” (ASHA, 2018b, para. 1).

Service Delivery Options

In addition to determining the type of speech and language treatment that is optimal for children with spoken language disorders, SLPs consider other service delivery variables—including format, provider, dosage, and timing—that may impact treatment outcomes.

Format

Format refers to the structure of the treatment session, including, but not limited to, the number of children in the session and the language(s) used. Children with spoken language disorders can use group treatment sessions to apply learned strategies and to practice language skills in natural contexts.

Clinicians can incorporate technology into service delivery, including computer-based treatment programs and the use of telepractice. Various types of assessments and interventions can be provided via telepractice; however, each state’s requirements for telepractice vary. See ASHA’s state-by-state resource for specific state rules and ASHA’s Practice Portal page on Telepractice.

For children who speak minoritized dialects of American English, consult with additional service providers with appropriate cultural and linguistic proficiency, including cultural informants or brokers, when necessary. See ASHA’s Practice Portal page on Cultural Responsiveness.

For multilingual children, it is important to consider the language(s) used during intervention. Multilingual clinicians who have the necessary linguistic and clinical expertise to treat the client may not always be available. In these cases, the SLP collaborates with an interpreter or a cultural broker. See ASHA’s Practice Portal pages on Multilingual Service Delivery in Audiology and Speech-Language Pathology and Collaborating With Interpreters, Transliterators, and Translators.

Provider

Provider refers to the person offering the treatment, such as the SLP or the caregiver. SLPs can train treatment extenders—including family members, caregivers, and volunteers—to implement specific interventions (see the Caregiver-Mediated or Caregiver-Implemented Intervention section above) and to encourage the carryover of learned communication strategies beyond the treatment setting.

Dosage

Dosage refers to the frequency, intensity, and duration of service. Dosage of treatment will vary based on the child’s goals and needs; additionally, more sessions does not always mean better outcomes (Frizelle et al., 2021). For more information about dosage in the school setting, see ASHA’s resource on school-based service delivery in speech-language pathology.

Setting

Setting refers to the location of treatment (e.g., home, community). Settings of school-based interventions can include the SLP resource room and/or in the classroom. For more information, see ASHA’s resource on school-based service delivery in speech-language pathology. Treatment extenders, following training from an SLP, can provide language practice in the home and in the community.

ASHA Resources

• Access to Communication Services and Supports: Concerns Regarding the Application of Restrictive “Eligibility” Policies
• Assessment and Evaluation of Speech-Language Disorders in Schools
• Cognitive Referencing
• Communication Bill of Rights
• Consumer Information:
• ASHA’s Developmental Milestones: Birth to 5 Years
• Childhood Spoken Language Disorders
• Let’s Talk: For People With Special Communication Needs
• Your Child’s Communication Development: Kindergarten Through Fifth Grade
• Cultural Competence Check-Ins
• Developmental Norms for Speech and Language: Collective Resource
• Dynamic Assessment
• Identify the Signs of Communication Disorders
• Individuals with Disabilities Education Act (IDEA)
• Information for School-Based SLPs
• Language In Brief
• Latest Forum From Perspectives Tackles SLI/DLD Terminology Discussion – ASHA Journals Academy
• Operationalizing the National Joint Committee on Learning Disabilities (NJCLD) Definition of Learning Disabilities for Ongoing Assessment in Schools
• Phonemic Inventories and Cultural and Linguistic Information Across Languages
• Response to Intervention (RTI)
• Social Communication Disorder
• Speech Sound Disorders: Articulation and Phonology

Other Resources

This list of resources is not exhaustive, and the inclusion of any specific resource does not imply endorsement from ASHA.

• African Social Pragmatics
• Developmental Language Disorder Resources:
• DLD and Me
• Language and Working Memory Lab: The DLD Diagnostics Toolbox
• National Institutes of Health: Developmental Language Disorder
• RADLD | Raising Awareness of Developmental Language Disorder
• The DLD Project
• Early Childhood Technical Assistance (ECTA) Center
• National Joint Committee on Learning Disabilities (NJCLD): Statements

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Alt, M., Mettler, H. M., Erikson, J. A., Figueroa, C. R., Etters-Thomas, S. E., Arizmendi, G. D., & Oglivie, T. (2020). Exploring input parameters in an expressive vocabulary treatment with late talkers. Journal of Speech, Language, and Hearing Research, 63(1), 1–18. https://doi.org/10.1044/2019_jslhr-19-00219

American Speech-Language-Hearing Association. (2004a). Admission/discharge criteria in speech-language pathology [Guidelines]. https://www.asha.org/policy/gl2004-00046/

American Speech-Language-Hearing Association. (2004b). Auditory integration training [Position statement]. https://www.asha.org/policy/

American Speech-Language-Hearing Association. (2016). Scope of practice in speech-language pathology [Scope of practice]. https://www.asha.org/policy/

American Speech-Language-Hearing Association. (2018a). Facilitated communication [Position statement]. https://www.asha.org/policy/

American Speech-Language-Hearing Association. (2018b). Rapid prompting method [Position statement]. https://www.asha.org/policy/

American Speech-Language-Hearing Association. (2023). Code of ethics [Ethics]. https://www.asha.org/policy/

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Acknowledgments

Content for ASHA’s Practice Portal is developed through a comprehensive process that includes multiple rounds of subject matter expert input and review. ASHA extends its gratitude to the following subject matter experts who were involved in the development of the Spoken Language Disorders page.

• Jessie Erikson, PhD, CCC-SLP
• Sandra L. Gillam, PhD, CCC-SLP
• Laura Green, PhD, CCC-SLP
• Megan-Brette Hamilton, PhD, CCC-SLP
• Alan Kamhi, PhD, CCC-SLP
• Karla McGregor, PhD, CCC-SLP
• Vicki Reed, EdD, CCC-SLP
• Mabel Rice, PhD, CCC-SLP
• Raul Rojas, PhD, CCC-SLP
• Elaine Silliman, PhD, CCC-SLP
• Geralyn Timler, PhD, CCC-SLP
• Carol Westby, PhD, CCC-SLP
• Kathleen Whitmire, PhD, CCC-SLP

ASHA seeks input from subject matter experts representing differing perspectives and backgrounds. At times a subject matter expert may request to have their name removed from our acknowledgment. We continue to appreciate their work.

Citing Practice Portal Pages

The recommended citation for this Practice Portal page is:

American Speech-Language-Hearing Association. (n.d.). Spoken language disorders [Practice portal]. https://www.Practice-Portal/Clinical-Topics/Spoken-Language-Disorders/