Expressive language disorder

Clinical features and classification

The main feature of this disorder is that the child's ability to use expressive spoken language is reduced below the mental age appropriate level, while language comprehension ranges within normal limits. Abnormalities in articulation may co-occur.

In ICD-10, the following symptoms are considered important for diagnosis (ICD-10, p. 237):(!.)

• delay of the development of expressive language (e.g. absence of single words by the age of 2 years, failure to generate simple two-word sentences by 3 years)

• restricted vocabulary development

• overuse of a small set of general words

• difficulties in selecting appropriate words and word substitutions

• short utterance length and immature sentence structure

• syntactical errors, especially omissions of word endings or prefixes

• misuse of or failure to use grammatical features such as prepositions, pronouns, articles, and verb and noun inflexions.

The DSM-IV criteria require measures of expressive language development being substantially below those obtained from standardized measures of both non-verbal intellectual capacity and receptive language development, interference with academic or occupational achievement, and the exclusion of mixed receptive-expressive disorder and pervasive developmental disorders.

Diagnosis and differential diagnosis

The diagnosis is made by clinical observation, with special emphasis on expressive language functions and the use of individually administered standardized tests of expressive language. The differential diagnosis should rule out mixed receptive-expressive language disorder (DSM-IV), characterized by an impairment of receptive language functions. Autistic disorder may also involve expressed language impairment, but autism can be distinguished by characteristic communication impairments. Finally, mental retardation and sensory impairments (e.g. hearing impairment or other sensory deficits) need to be ruled out, as well as severe environmental deprivation. The diagnosis is confirmed using intelligence tests, audiometric tests, neurological investigations, and a careful history. Finally, acquired aphasia needs to be ruled out. This can be done by assessing any medical condition that may have caused the disorder.


In the absence of thorough epidemiological studies, estimates suggest that between approximately 3 and 5 per cent of children may be affected by expressive language disorder of the developmental type. The acquired type seems to be less common.


DSM-IV distinguishes two types of expressive language disorders: the developmental type and the acquired type. In the developmental type, impairment of expressive language begins at a very early age and is not associated with neurological factors, while the acquired type occurs after a period of normal development and is caused by neurological or general medical conditions (e.g. head trauma, encephalitis). It is assumed that the developmental type is caused by genetic factors that influence language development.

Course and prognosis

The course depends on the type of disorder (developmental or acquired type) and severity. Usually, the disorder can be diagnosed by the age of 3 years, whilst milder forms are often only detected later. According to DSM-IV, (3> approximately half of the children appear to outgrow the developmental type of expressive language disorder, while the other half have persistent difficulties. The outcome of the acquired type depends on the severity and location of the brain pathology.


As causal treatment is not possible, treatment measures are based on general principles that have been found to be useful and effective in clinical practice.

!. The first step is to explain clearly to parents the nature of the disorder and the fact that several other disturbances manifested by the child may be a result of the child's communication deficit.

2. The best time to commence speech therapy depends upon the severity of the disorder, the child's cognitive and motivational structure, and other disorders that might be present. Instead of treating children too early (e.g. before the age of 3 years), offering advice and guidance to the parents is extremely important.

3. Treatment itself concentrates on teaching language skills using techniques such as imitation and modelling. The therapist should focus interventions selectively on the areas of difficulty, thus increasing the child's phonological repertoire. Non-verbal communication techniques may be used if verbal communication is substantially impaired. But the therapist should always make sure that non-verbal communication does not dominate the verbal one.

4. In therapeutic programmes, everyday situations are now preferred to very structured programmes. This is because many therapists found that therapeutic progress during sessions was not transferred to everyday life situations. During structured treatment sessions the children are taught to give correct answers to questions that have nothing to do with their situation in everyday life, and it is now thought that structured language training may prevent them using language according to their needs.

5. Alternative communication, such as sign language, should only be used if the child suffers from severe auditory comprehension deficits. The use of a sign language, however, is no longer regarded as an obstacle to the improvement of expressive language skills. (6)

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