'Literature Review'

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					     Relating language and
 communication problems to
  anti-social behaviour, youth
offending and emotional and/or
    behavioural difficulties.

       ‘Literature Review’

         Angela Sloan
   YISP Speech and Language

1. For reference: the incidence of speech and language difficulties amongst the
‘normal’ population of UK children has been difficult to establish. Studies vary from
between 5 and 10% (the most recent research I’m aware of [2000] came up with
10%, i.e. 1 in 10 children at some point in childhood has a significant speech/language
difficulty). These difficulties are not confined to children in their early years.

2. The country for each study below has been noted where known.

3. Psychiatric settings in the US tend to include referrals of children with less severe
behaviour problems, which wouldn’t necessarily be referred to a psychiatrist in the UK.

4. Useful definitions (from Benner et al 2002):
• Communication = speech and language
• Speech = a verbal means of communicating
• Language = a socially shared code to communicate meaning (receptive and expressive,
    includes use, grammar/structure, vocabulary)
• Receptive language = understanding language
• Expressive language = using/producing language
• Pragmatic skills = component of language concerning the rules relating to using language
    in a social setting, e.g. turn-taking, eye contact etc.

Allen and Wasserman 85
Found that “abusing mothers” were more likely to ignore their children.

Allen and Rapin 80
Language acquisition is an integral part in the development of an individual.

Australian Temperament Project (Crime Prevention Victoria) - Report
Longitudinal study of 3 groups of ‘antisocial’ young people (violent only, non-violent
only, violent and non-violent:dual). All groups had a high prevalence of lower social
skills than control groups. ‘Violent’ group had increased difficulties in interpersonal
relationships. ‘Dual’ group – parental perception of the child as ‘difficult’, early
language delay noted for 20%.

Beadle 79
Found pre-schoolers with expressive language problems are ‘at risk’ for poor
attention, emotional lability, impulsivity and high levels of alertness.

Beitchman 85 (US)
60% of 5 year-olds with speech and language impairments received a psychiatric
diagnosis, compared to 12% of a control group. Children with less obvious
difficulties with receptive and expressive language may not be identified as having
language problems but may be referred to support services for other reasons, e.g.
behavioural issues. Also agreed with Beadle’s findings on behavioural characteristics
for children with expressive language problems, but different for receptive problems,
e.g. mild receptive language difficulties linked to temper tantrums and negativism;
children with severe receptive difficulties likely to show behaviours similar to
children on the autistic spectrum.

Beitchman et al 94 (US)
7 year follow-up of children diagnosed as speech/language impaired at age 5 years:
72% remained impaired, especially if speech and language impaired or both receptive
and expressive difficulties present.
Those children with auditory comprehension problems at age 5, showed increased
hyperactivity at age 12.
Children with age-appropriate language comprehension at age 5, scored highly on
social competence and adaptive functioning at age 12; children with histories of
pervasive language difficulties or auditory comprehension problems scored poorly on
mother- and teacher-rating scales and had more marked behavioural disturbance at

*Benner, Nelson and Epstein 02
Reviewed literature on language skills of children with EBD. Looked at 26 studies.
71% of children formally identified with EBD had clinically significant language deficits
(broad range of deficits). 57% with diagnosed language problems were identified
with EBD. Over time the comorbidity between language difficulties and EBD stays
stable or increases. Prevalence varies across studies depending on where the
children are placed and how language deficits are measured/determined.
Review of literature on the relationship between language problems and antisocial
behaviour shows:
1. Children with pure language deficits (especially in the area of understanding) are
    at much higher risk for antisocial behaviour (and reading difficulties) than those
    with speech disorders or speech-and-language disorders. (See also Cohen et al
2. Receptive language problems frequently go undetected and are linked to higher
    rates of behaviour difficulty in children, as opposed to those who have specific
    expressive problems.
3. Estimated that children presenting with antisocial behaviour are 10 times more
    likely than the general population to have language difficulties.
4. Language disorders have a devastating effect on interpersonal relationships (e.g.
    with peers, family, spouse/partner) throughout life. Do difficulties in initiating
    and maintaining relationships lead to/exacerbate antisocial behaviour?

*Bone, Parker and Robinson 02
On Track: Brighton and Hove. 4-12 year olds with emotional and/or behavioural
problems. 86% had some degree of speech and language difficulty. 78% of these had
a previously unknown language problem.

Botting and Conti-Ramsden 00
Studied children with speech and language impairment in Year 2. 40% had additional
anti-social or emotional problems. Most likely to experience behaviour problems if
had a combined receptive and expressive language difficulty. Behaviour difficulties
increase with age (?if underlying difficulties unmanaged).
Bryan 00-01 (UK)
Screened 10% of young offenders in one establishment: 47% rated as having a
moderate speech difficulty (half of this group reported having a stammer or being
told they had a stammer).
Very little research has been conducted to determine the incidence of speech and
language disorders within the prison population, but there are indications that the
prevalence of these difficulties is much higher than the general population.

*Burgess and Bransby 90 (UK – Surrey)
16 out of 17 children (6-12 years old) in a Unit for children with moderate
emotional and behavioural problems presented with speech and/or language
difficulties which required SLT intervention. These difficulties had not previously
been identified.

Camarata et al 88
School-based study: 89% of 9 to 12 year-old mild/moderate behaviour disordered
children had significant language problems. (71% had language scores more than 2
SD below the mean).

Cantwell and Baker 82
44% of 291 children from a community-based SLT clinic also had behavioural

Cantwell and Baker 85
Children with language disorders are consistently shown to be at risk for psychiatric

Cantwell and Baker 87
Children with speech and language delay or disorder are at risk of developing
emotional/behavioural difficulties and learning difficulties.    Children with
speech/language problems may be put under pressure to conform when unable to
understand or respond appropriately, which could lead to behaviour (e.g. poor
attention, non-compliance, tantrums) interpreted as ‘bad’ behaviour. Then the
behaviour becomes the focus of intervention as opposed to the underlying language

Cantwell and Baker 91
Language disorders are as common among children with psychiatric problems as
psychiatric problems are among language disordered children.

Casey and Schlosser 94
Children with externalising behavioural problems seem to have less control over
their own facial expression and less understanding of their own emotions than their
peers do.

Cassidy 94
Some children who experience rejection when they are distressed, tend not to show
negative emotions in order not to re-experience rejection. This is likely to affect
their ability to interact appropriately with others in the long-term.
Chess and Rosenberg 74 (US)
40% of preschoolers attending a private psychiatric practice had language problems.

Cohen et al 89 (Canada)
Suggest that language disorders in children with antisocial behaviour or conduct
problems are going undetected. Children aged 5-12 in a psychiatric outpatient
setting: 28% previously unidentified moderate or severe language disorder. (This
group tended to have externalising problems and conduct problems). This group
had more receptive and listening difficulties than those children previously identified
as having a language problem. Therefore there is a sizeable proportion of children
whose language difficulties are overlooked possibly because of their disruptive and
therefore more salient behaviour problems. Language disorders can interfere with
cognitive development and cause or exacerbate behaviour problems: therefore
routine language screening of child psychiatric populations is required.

Cohen 90 (Canada)
Sample of 100 children attending psychiatric clinic: 38% prevalence of unsuspected
language disorder (often had externalising problems). Note: used measures of
auditory memory here, which they didn’t do in 1989 study.

Cohen and Lipsett 91 (Canada)
From 237 children (between 4 and 12 years old) attending one of 3 mental health
clinics: 38% had previously unrecognised language impairment. Behaviour of the
children with language difficulties was regarded as more difficult by teachers (than for
those with normally developing language), and findings suggest that children with
unsuspected language impairment are perceived as more ‘difficult’ than when the
impairment is recognised. We need to help adults understand their potential
misperceptions and misattributions of child behaviour.

Cohen et al 93 (Canada)
Children with emotional and behavioural problems often have communication
difficulties, but these frequently go undetected. Children with unsuspected receptive
language difficulties are rated as the most delinquent and depressed by parents and
as the most aggressive by teachers. They showed the most challenging behaviour.
Children with primarily expressive problems were rated as most socially withdrawn
and anxious.

Cohen et al 98
Incidence of undetected speech and language impairment is higher in the 7-14 year
old group referred to psychiatric services (as opposed to the 4-12 year-old group).
Children with undetected language difficulties more likely to show ‘aggressive,
delinquent’ behaviours and get diagnoses of oppositional defiant or conduct disorder.

Cook et al 94
Children with behavioural problems are less likely to talk about their emotional
experiences and are less likely to identify how others are feeling.

Coster et al 89
Toddlers who had been abused were less likely to ask for information. They used
significantly fewer utterances describing how their felt or what they were doing and
had a lack of conversational skills. ?because they got less praise when they tried to
talk and more verbal aggression when they did, as opposed to controls.

Cross 97
Evidence that children with emotional and behavioural difficulties often have an
undetected language or communication problem.

Cross 99
Children with emotional and behavioural problems who are “Looked After” by the
Local Authority are also likely to have communication difficulties (many of which go

*Cross et al 01
‘Actions Speak Louder Than Words?’ Case study showing improvements in
communication skills and behaviour, academic progress and increases in self
esteem, following multidisciplinary, collaborative interventions.

Crowe 91 (US)
USA studies suggest 10-15% of prison population have a significant communication

Digital Public Health Report 01 – Young Offenders
Brighton and Hove YOT and East Sussex YOT identified a gap in SLT service to
young offenders. Data from ASSET identifying the needs of young offenders,
including SLT needs (L. Wolfe, 00 ) contributed to this report. There was also a
proposed model of SLT intervention for young offenders (Baker) – I have this*.

Dodge et al 95
Children who had been maltreated were particularly aware of hostile cues in the
environment but may also interpret neutral actions as hostile (This is likely to affect
their accurate interpretation of non-verbal and verbal communications. AS)

Erickson 89
Children who have been abused seem to find it difficult to understand others’
emotions as well as their own, which may have a negative impact on their ability to
interact appropriately.

Fujiki et al 99
Children prone to non-compliance may have receptive language difficulties, which
restrict their ability to understand and comply with repeated warnings or verbal
cues. (This can lead to misinterpretation of communication, frustration and the
development of chains of miscommunication and antisocial behaviour patterns.)

Gallagher 99
Aggressive children use less verbal communication and more direct physical actions
to solve interpersonal problems due to limited language skills.

Gesten et al 86
Pre-schoolers with secure parent-child attachments used more complex language
than cognitively matched maltreated children.
Giddan et al 96 (North America)
Many children with emotional and behavioural problems also have language
difficulties that go undetected. (Preadolescent inpatients: psychiatric settting)

Gordon 1991
If teachers aren’t aware that a child in their class has speech and language difficulties,
the student’s behavioural responses may give rise to perceptions of primary
problems such as emotional and behavioural disorders.

Gualtieri et al 83
At least 50% of children (40 consecutive admissions to an inpatient psychiatric unit:
serving lower SES children) had language difficulties. These language disorders may
go undetected unless there is routine screening/assessment of the language skills in
psychiatrically disturbed children.

Hamilton 99 (Scotland)
Study of young offenders: 11% had a communication problem (at least 10 % of this
sample had a stammer).

Hammond et al 90
Language difficulties for 22 out of 27 (82 %) non-accidental burn cases, as opposed to
in 5 out of 12 (42%) accidental burns cases.

Heneker et al 03 (not yet published)
91% prevalence of communication difficulties in a unit for children with EBD.
?Showed some evidence of improvement in behaviour following SLT intervention.

Hess and Cicchetti 82
Learning to label emotions may help to manage them (i.e. and increase self control).

Johnson 94 (Polmont Young Offenders Survey)
10-20% of young offenders in the UK serving more than 3 months were found to
have significant communication problems.

Jones and Chesson 00 (UK)
Found a higher than normal incidence of language difficulties in children with mental
health problems. (Frequently undetected!). Screening language skills recommended
for all referrals to child mental health with SLT available for assessment, intervention
and staff training (to increase awareness).

Kaler and Kopp 90
Seem to be strong links between emotional and behavioural difficulties and language

Kendall and Braswell 85
Language development is vital for the development of ‘inner speech’ which mediates
between intention and action.
Law and Conway 89
In a literature review on child abuse and language development, they concluded that
‘neglect’ has the most serious effect on language development, especially when it
affects attachment.
Social use of language is most likely to be affected in children with behaviour

Love and Thompson 88
65% of children had language difficulties in a preschool psychiatric outpatient clinic.

McCann et al 96, Hayden 97
The medical/psychiatric needs and educational needs of children ‘looked after’ by the
Local Authority often go unmet.

McCauley and Swisher 87
Argue that speech and language problems in a child may lead to neglect and this can
then lead on to emotional and behavioural problems.

Miniutti 91
Inner city school setting: 6-9 year old children with learning and behaviour problems.
Over 75% had significant language difficulties. Strong association between language
impairments and behaviour disorders as rated by teachers. Both receptive and
expressive language difficulties for the behaviour disordered children.

Naylor et al 94
School refusers had significantly higher incidence of both language impairments and
learning difficulties than controls. (These children were unable to meet the academic
and social demands in school due to their language and learning problems).

Ontario Association for Families of Children with Communication
Disorders (website)
Reference to 60% of young offenders having some form of communication disorder
(?in Canada, ?which study)

Paul 91
Hypothesised that the early maladaptive behaviour of toddlers is caused by
frustration at being unable to communicate effectively.

Pine 85
Language is important to be able to communicate how we are feeling.

!Prizant et al 90
There are some indications that the identification of communication difficulties can
improve behaviour and their clinical experience suggests a direct positive correlation
between improvement in communication and improvement in emotional and
behavioural problems.

Pryor 98
Study of young offenders: recommended SLT services in prisons. 64% had
significantly lower scores for expressive language than for receptive language.
Ripley 84 (UK)
Study: 71% of adolescents with speech and language impairment who had been
referred to a psychiatrist for aggressive behaviour, had expressive language

*Ripley and Yuill 03 (due to be published) (UK: ?East Sussex)
Investigated language impairment in excluded children (boys 8-16 years old). Many
of the excluded boys had previously unidentified language problems, supporting the
need for early recognition and assessment of language for boys with behaviour
problems. Expressive problems were linked to high levels of emotional symptoms
(area for further investigation). Concluded: ‘the early recognition of language and
emotion difficulties, followed by appropriate intervention to enable such children to
have access to the curriculum, to develop appropriate social skills and emotional
literacy, may be a first step towards reducing the rates of exclusion from school and
promoting social inclusion’.

Sage 02 (UK)
Impairments in narrative skills are commonly seen amongst students with emotional
and psychiatric difficulties, preventing them negotiating solutions to personal and
academic problems. A Communication Opportunity Group Scheme (COGS) was
successful for many of these students and helped to develop formal language and

Sanger et al 2003 (USA)
Implications of a study of 13 female young offenders (in a correctional facility), aged
13-17 years, with language problems: concerns raised about whether the educational
system is adequately considering how language difficulties impact on this troubled

Schaffer 89
Evidence that a responsive relationship with a caregiver (i.e. ‘secure attachment’
[Ainsworth 78]) is important for both language and emotional development.

Silva et al 87
Prognosis for those with language problems in the ‘normal’ population is poor with
regard to school performance and emotional development. (So if there are already
emotional and behavioural difficulties, language problems could exacerbate behaviour
difficulties and further impair cognitive development. AS)

Silva et al 94
In a group of 3 year-olds, there was a higher incidence of behaviour problems for
children with receptive language difficulties. Also found a group of children aged 11
years old, who had expressive language problems which had not been apparent at
the age of 9 years. Also children with combined receptive and expressive language
problems are most likely to experience behaviour difficulties, especially in
relationships with peers.
Sivyer 99
Evidence to suggest that there is a good case for developing SLT intervention for
children in PRUs or at risk of exclusion. Need to look at ways of supporting staff to
continue SLT groups (which covered behaviour management, language and social
communication skills, and self esteem) and of increasing links with parents, both to
aid generalisation and effectiveness.

Snow, P. (On website, Australia 02/03?)
Much known re: poor literacy skills in young offenders; less known re: spoken
language abilities.

Snow and Powell (2002 – proposed study: Australia) *need to investigate further
Young offenders are a complex and challenging population with high rates of
comorbidity between attentional, learning and behaviour problems. Few workers
have, however, considered the underlying language processing and production skills
in this population. Available evidence indicates a high level of vulnerability to
language disorders in young offenders. These may contribute to poor academic
performance and failure to develop prosocial skills. This study will describe their
relationship to social skills, pattern co morbidity and type of offence (property v.
violent). Findings will be relevant to theories of juvenile offending and design of
prevention/intervention programmes.

Stevenson et al 85
Children with language problems at 3 years old were at risk of showing behaviour
problems at 8 years. As language skills improve, accompanying ‘difficult’ behaviours

Toppleberg 00
Communication difficulties, particularly receptive language disorders, have emerged
as high risk indicators for psychiatric difficulties.

Vygotsky 62
Key tool for the self- regulation of behaviour is language. Self-talk is internalised as
thought between ages of 6-7 years (talking through possibilities of action/planning
ahead – rather than acting them out).

Warr-Leeper 94
80% of ‘anti-social’ boys in a residential treatment centre had undetected language

Warr-Leeper 02
Relationship between language disorders and behavioural disorders is not well
understood, but the importance of developing adequate communication
skills has been established: language is the main way of developing social
relationships, a major means of organising behaviour, central to the successful
acquisition of many cognitive and academic skills, especially literacy. Prevalence of
language problems in school-aged children with behaviour disorders: 71-89%; 10
times higher than estimates in the general school population. School-aged children
with language and behaviour problems tend to have:
•   consistent difficulties with listening, especially for material out of context, which
    has to be processed quickly
•   difficulties understanding multiple meanings of words (e.g. ‘bat’ as in cricket and
    as in flying mammal) and figures of speech/idioms (e.g. pull your socks up, raining
    cats and dogs)
•   difficulties with inference, i.e. filling in/deducing missing information
•   difficulties producing complex sentence structures (e.g. joining sentences

Weiner 85
Failure of the language system can have effects on social, educational and vocational
success. Language impairments can remain into adulthood.

Wiig and Semel 84
The effects of language difficulties on social, academic and vocational achievement
will not be alleviated if left unmanaged.

Angela Sloan
Brighton & Hove YISP
Feb 2004

01273 420770