Communication Disorders and Emotional/Behavioral Disorders in Children and Adolescents

Abstract

Recent research in child psychiatry has demonstrated a high prevalence of speech, language, and communication disorders in children referred to psychiatric and mental health settings for emotional and behavioral problems. Conversely, children referred to speech and language clinics for communication disorders have been found to have a high rate of diagnosable psychiatric disorders. Most of the emerging knowledge regarding relationships between communication disorders and psychiatric disorders has been presented in the child psychiatric literature. Speech-language pathologists and audiologists also need to be familiar with this information; an understanding of the complex interrelationship between communication disorders and emotional and behavioral disorders is important for diagnosis, assessment, and treatment. The purpose of this article is to review recent research and discuss clinical implications for professionals in speech-language pathology and audiology working with children and adolescents who have, or who are at risk for, developing emotional and behavioral disorders. Issues to be addressed include differential diagnosis, prevention, intervention, and the role of speech-language pathologists serving these children and adolescents.

Full text

Journal
of
Speech
and
Hearing Disorders,
Volume
55, 179-192,
May
1990
THEORETICAL
ISSUES
The
Relationship
Between
Communication
Disorders
and
Psychiatric Disorders
Recent research
has
demonstrated that
there
is
a
rela-
tionship
between
communication disorders, emotional
disorders,
and
behavioral disorders
in
children
and
ado-
lescents
(Baker
&
Cantwell,
1987a;
Gualtieri,
Koriath,
Van
Bourgondien,
&
Saleeby,
1983).
Following
a
compre-
hensive
literature
review,
Baker
and
Cantwell
(1987b)
concluded
that
"the
literature
strongly suggests
that
chil-
dren
with
delays
or
disorders
of development
in
speech
or
language
are
'at
risk'
for
both psychiatric
and
learning
disorders"
(p.
546).
Most
speech-language pathologists
who
work
with
children
and adolescents
with communi-
cation
disorders have
been
challenged
by
the
behavioral
and
emotional
difficulties
experienced
by
some
of
their
clients.
Baker
and
Cantwell
(1982a),
a
child
psychiatrist
and
developmental
psycholinguist
respectively, noted,
Conferences
with
speech
pathologists
will
elicit
the
uni-
form
opinion that the
patients
that
they
are
seeing
in
their
practices
are
frequently
emotionally
disturbed.
But
such
clinicians will
be unable
to
quantify
how
many, how
seriously,
or
more
important,
which of
the
children
they
see
are
so
affected.
(p.
291)
The
nature
of
this
relationship
has
been
discussed
in
publications
of
the
American
Speech-Language-Hearing
Association
as
early
as
the
1950s
when
McCarthy
(1954)
suggested
that
certain
personality
traits
are
associated
with
language
disorders
in
children. Trapp
and Evan
(1960)
noted that
children
with
articulation
disorders
have anxiety
levels
that
correspond with
the
level
of
severity
of
their
articulation disorder.
Waller,
Sollod,
Sander and
Kunicki
(1983)
stated,
"Interest
in
a
relation
between
functional
speech/language disorders
and
psy-
chopathology
is
hardly
new
to
our
profession"
(p. 94).
However, this
interest
historically
has
taken
the
form
of
theories
as
to
the
cause/effect
relationship
between
psy-
chological
dynamics
or
personality and speech,
fluency,
articulation,
and
language
disorders.
Furthermore,
earlier
accounts often
were
derived
from
clinical
experience
or
were
based
on case
studies,
and
there
was
considerably
less
emphasis
on
relationships
between
communication
disorders
and emotional/behavioral disorders.
In
recent
years,
there
has
been
a
renewed
interest
and reemphasis
on
these
relationships,
resulting
in
an
emerging
body
of
research and
clinical
literature.
This
newer
information
supports
the
need
for
speech-language
pathologists to
keep
this
relationship
in
mind
when
approaching
the
diagnosis
and
treatment
of speech-language-impaired
children. Thus,
speech-language pathologists
need
to
become
familiar
with
this
literature and the
issues
gen-
erated
by
this
renewed
interest.
©
1990,
American
Speech-Language-Hearing
Association
COMMUNICATION DISORDERS
AND
EMOTIONAL/BEHAVIORAL
DISORDERS
IN
CHILDREN
AND
ADOLESCENTS
BARRY
M.
PRIZANT
Brown
University Program
in
Medicine
Providence,
RI
and
Bradley
Hospital
East
Providence,
RI
LISA
R.
AUDET
GRACE
M.
BURKE
LAUREN
J.
HUMMEL
SUZANNE
R.
MAHER
GERALDINE
THEADORE
Bradley
Hospital
East
Providence,
RI
Recent
research
in
child
psychiatry
has
demonstrated
a
high
prevalence of speech,
language,
and
communication
disorders
in
children
referred
to psychiatric
and
mental
health
settings
for
emotional
and
behavioral
problems. Conversely,
children
referred to
speech and
language
clinics
for
communication
disorders
have
been
found
to
have
a
high
rate
of
diagnosable psychiatric disorders.
Most
of
the
emerging knowledge
regarding
relationships
between
communication disorders
and
psychiatric
disorders
has
been
presented
in the
child
psychiatric
literature.
Speech-language
pathologists
and
audiologists
also
need
to
be
familiar
with this
information;
an
understanding
of
the
complex
interrelationships
between
communication
disorders
and
emotional
and
behavioral
disorders
is
important
for
diagnosis,
assessment,
and
treatment.
The
purpose
of
this
article
is
to
review
recent
research
and discuss
clinical implications
for
professionals
in speech-language
pathology
and
audiology
working with
children
and
adolescents who
have,
or
who
are at risk
for,
developing
emotional
and
behavioral disorders.
Issues
to
be
addressed
include
differential
diagnosis,
prevention, intervention,
and
the
role
of
speech-language pathologists serving
these children
and
adolescents.
KEY
WORDS:
emotional disorders,
behavioral disorders, communication disorders,
psychiatric disorders, speech-language
pathologists
179
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180
Journal
of
Speech
and
Hearing
Disorders
Recently, researchers in
speech-language
pathology
have
begun
to
explore
these
issues by
studying
topics
such
as
types
of
communication disorders
in
child
psychiatric
populations
(Baltaxe
&
Simmons,
1988a,
1988b),
self-con-
cept
in communicatively
disordered children
(Brandell
&
Wirhanowicz,
1985),
language
disorders in
children
with
mild/moderate
behavioral
disorders
(Camarata,
Hughes,
&
Ruhl,
1988)
communication
disorders
in
abused
and
ne-
glected
children
(Bloom
& Collins,
1987),
and
language
and speech
disorders
in an
inpatient
psychiatric
setting
(Burks,
1987).
These
studies
have
documented
a
high
prevalence
rate
of
co-occurrence
of communication
disor-
ders
and
emotional/behavioral disorders
in
children
and
adolescents.
Rates
of
co-occurrence
vary
according
to
the
specific
settings
and
subjects
in
these
studies.
Researchers
have
discussed
the potential
conse-
quences
of
communication disorders
in
children.
Baker
and
Cantwell
(1983)
noted that
since language
is
a
uniquely
human
quality, it
is
therefore
not
unexpected
that
a
disorder
in
language
development
might
have
far
reaching
consequences
for
other
areas
of
early
childhood development.
In
fact,
systematic research
has
suggested
that
language
is
uniquely
and
intrinsically
related
to
the development
of the
child's
thought,
play
activities,
social
and
emotional
development
and learning.
(p.
51-52)
An
understanding
of
the relationship between
commu-
nication
disorders,
emotional
disorders, and behavioral
disorders
in
children
and
adolescents
is
critical
if
the
needs
of
the children
served
by
speech-language
pathol-
ogists are
to
be
met.
Diagnosis
of
Psychiatric
Disorders
Baker
and Cantwell
(1987a)
provided
the
following
working
definition
of
psychiatric disorder:
"a
disorder
of
behavior,
emotions
or
relationships
that
is
sufficiently
severe and/or
sufficiently
prolonged,
to
cause
disturbance
in
the
child
or
disruption of
his
immediate environment"
(p.
193).
Adult
and childhood
psychiatric disorders
cur-
rently
are
diagnosed
according
to
DSM
III-R
(1987),
a
taxonomy
that
has
its
origins
in
a
classification
system
originally
adopted
in
1889.
The
Diagnostic
and
Statistical
Manual
of
Mental
Disorders-I
(1951)
was
revised
and
updated
with
three
subsequent
versions:
DSM
11
(1968),
DSM
III1
(1980),
and
the
current
classification system,
DSM
III-R
(1987).
When
reviewing
psychiatric
literature,
it
is
important
to
be
cognizant
of the
various taxonomies
that
have
been
used
over
the
years,
for
diagnostic categories
and
criteria
for
diagnosis have
changed
considerably.
The current
DSM
III-R
(1987)
multiaxial system
con-
sists
of
five
axes
(see
Table
1).
Axis
I
includes
clinical
syndromes.
A
clinical
syndrome must
have
as
essential
features
"a
group of
symptoms
that
occur
together
and
constitute
a
recognizable
condition"
(DSM
III-R,
1987,
p.
405).
For
example,
Attention-Deficit Hyperactivity
Disor-
der
(ADHD),
a
subcategory
of Disruptive
Behavior
Disor-
ders,
is
defined
by
"developmentally
inappropriate
degrees
TABLE
1.
DSM
III-R
multiaxial
system
(APA,
1987).
Axis
I
Clinical syndromes
V
Codes
Axis
II
Developmental
disorders
Personality disorders
Axis
III
Physical
disorders and
conditions
Axis
IV
Severity
of
psychosocial
stressors
Axis
V
Global
assessment
of functioning
of inattention,
impulsiveness and
hyperactivity"
(DSM
III-R,
1987,
p.
50).
Other
examples
of
categories
of
Axis
I
disorders
are
Schizophrenia,
Mood
Disorders,
and
Anxiety
Disorders.
Also
included
under
Axis
I
are
V
Codes.
V
Codes
are
problems
not
attributed
to
a
mental disorder,
but
are
the
focus
of attention
or
treatment. Examples
of
V
Codes
in-
clude
academic
problems
not
necessarily
related
to
specific
skill
deficits,
mother-child
relationship
problems,
or
sexual/
physical
abuse.
Axis
II
includes Developmental
Disorders
with
subcategories
of
Mental Retardation,
Specific
Devel-
opmental
Disorders,
and
Pervasive
Developmental
Disor-
ders.
Axis
II
also
includes
Personality Disorders.
All
of
these
Axis
II
diagnostic categories reflect
patterns
of
behav-
ior
that
are
long
standing
and
not
easily
resolvable.
Exam-
ples
of
Specific
Developmental
Disorders
include
Devel-
opmental Receptive
and
Expressive
Language
Disorders,
Developmental
Articulation
Disorder, Developmental
Reading
Disorder,
Developmental
Expressive
Writing
Dis-
order,
Developmental
Arithmetic
Disorder, and
Develop-
mental
Coordination
Disorder.
Pervasive
Developmental
Disorders
include
Autistic
Disorder
and
Pervasive Devel-
opmental
Disorder
NOS
(not
otherwise
specified).
Person-
ality
Disorders
include
categories
such
as
Paranoid,
Anti-
Social,
and
others.
Axis
III
includes
physical
disorders and medical
con-
ditions such
as
sensorineural hearing
loss
or
cerebral
palsy.
Axis
IV
is
a
continuum rating
of
severity
of
psycho-
social
stressors
(i.e.,
none, mild,
moderate,
severe,
ex-
treme,
catastrophic).
Psychosocial
stressors
include
a
va-
riety
of
events
that happen
within
an
individual's
environment that
cause
distress and
require
adaptation.
Expulsion
from
school,
the birth
of
a
sibling, and
sexual/
physical
abuse
are
examples of psychosocial
stress. Axis
V,
Global
Assessment of
Functioning,
is a
rating
of mental
health that
takes into
consideration
the
psychological,
social,
and
occupational
functioning
of
the
individual.
A
rating
is
made
on
a
scale
of 1-90
with
1
being
persistent
danger
of
severely
hurting self
or
others
andlor
inability
to
maintain
minimal
personal
hygiene,
and
90
being
absence
of
symptoms.
Baltaxe
and
Simmons
(1988a)
presented
a
breakdown
of
seven
ways,
which
are
not necessarily
mutually
exclu-
sive,
that
communication
handicaps
can
occur
within
the
DSM
III
(APA,
1980)
framework:
1.
The
communication
handicap
may
constitute the
sole
mental disorder.
This
is
the
case in
the
diagnosis
of
developmental
language
disorder,
stuttering,
and
elec-
tive
mutism.
2.
The communication
handicap
may
co-occur
with
an-
other
mental
disorder
without
obvious ties
to
that
55
179-192
May
1990
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PRIZANT
ET
AL.:
EmotionallBehavioral
Disorders
181
disorder.
This
is
the
case
when
a
communication
hand-
icap also occurs in
the
presence
of
another
psychiatric
diagnosis, such
as
conduct
disorder
or
anxiety
disorder.
3.
The
communication
handicap
may
be
part of the
essen-
tial
criteria
for
the
diagnosis
of
a
specific
mental
disor-
der.
This
is
the
case
in
the
diagnosis
of infantile
autism
and
pervasive
developmental
disorder,
where
lan-
guage
deficits
are
specifically
listed
as
essential
diag-
nostic
criteria.
4.
The
communication handicap
may
constitute
an asso-
ciated
characteristic
in the
diagnosis
of
a
mental
disor-
der. For
example,
a
communication
handicap
in
the
form
of
a
developmental
delay
is
presumed
to
be
present
in
the
diagnosis
of mental
retardation.
There,
the
developmental
language
lag
may
represent
an
as-
pect
of
the
overall
level of cognitive
functioning.
The
language
handicap in
this
case
is
not
specifically
listed
among
the
diagnostic
criteria.
5.
Underlying processing
difficulties commonly
associ-
ated
with
communication
handicaps
may
also
consti-
tute
characteristics
of the
psychiatric
diagnosis.
For
example, auditory
processing
difficulties
are
commonly
associated with
communication
deficits.
They
are
also
associated
with
the
psychiatric
diagnosis
of
attention
deficit disorder.
6.
Communication
handicaps
may
constitute
essential
characteristics
in
the
diagnosis
of
a
thought disorder
in
cases
of
psychosis
and
schizophrenia. In
this
example,
specific
pragmatic
deficits
involving
speaker-hearer
re-
lations
are
present.
7.
Prolonged
communication
failure
may
lead
to
second-
ary
psychiatric
problems.'
As
is
apparent,
in
the
DSM
III
(1980)
and
DSM
III-R
(APA,
1987)
classification systems,
many psychiatric
dis-
orders have
speech
and
language
symptomatology spe-
cific
to
the
overall
diagnosis.
As
will
be
discussed
later,
this
poses
a
challenge
to
differential
diagnosis
between
communication disorders and
psychiatric disorders.
Research
on
the
Relationship
Between
Communication
and
Emotional/Behavioral
Disorders
Researchers
in
child
psychiatry
have
established
an
empirical
base
substantiating
the
relationship
between
communication disorders and
psychiatric disorders
(Bak-
er
&
Cantwell,
1982b,
1987b;
Beitchman,
Nair,
Clegg,
Ferguson,
&
Patel,
1986;
Cantwell,
Baker,
&
Mattison,
1979,
1981;
Gualtieri
et
al.,
1983).
Gualtieri
et
al. (1983)
surveyed
40
consecutive
admissions
to
a
child
psychiatric
inpatient
facility.
They
found-after
in
depth
speech,
language, and
intelligence
testing-that
20
of
the
40
admissions had moderate
to
severe
language
disorders.
They
then
concluded
that
"there
appears
to
be
a
strong
association
between
developmental
language
deficits
and
severe psychiatric
disorders"
(p.
168).
They
added
that
"disorders
of
the
development
of
language
are
likely
to
be central
to
the
development of
human personality.
'From
Seminars
in
Speech
and
Language,
8,
by
C.
Baltaxe
and
J.
Simmons,
1988,
New
York:
Thieme
Medical
Publishers.
Copy-
right
1988
by
Thieme
Medical
Publishers. Reprinted
by
permis-
sion.
Understanding
and correcting deficiencies
of
language
can
improve
behavior
and
help
a
child
resolve
at
least
some
of
his
emotional dilemmas"
(p.
169).
Baker
and Cantwell
(1982b)
studied the
prevalence
of
psychiatric
impairment
in
speech- and
language-
impaired
children
seen
at
a
community-based speech
clinic
(age
range:
1 year
11
months-15
years
11
months).
Of
the
first
291
children
studied,
44%
had
some
psychi-
atric
illness
according to
criteria
in
the
Diagnostic
and
Statistical
Manual
of
Mental
Disorders-Third
Edition
(APA
1980).
They
found
that
children
presenting
with
a
"pure
language
disorder"
(n
=
19)
of
language
expres-
sion,
comprehension,
or
processing,
but
with
speech
being
normal,
were
the
most
seriously
at
risk
for
the
development
of psychiatric
disorders
(95%
prevalence
rate)
and had
the highest
mean
age
(M
=
9.3
years;
SD
=
3.4).
The prevalence
rates of
psychiatric
illness and
mean
ages
for
the
"pure
speech
disordered"
(n
=
108)
was
29%
and
6.0
years
(SD
=
2.6),
respectively,
and
for
the
"speech-and-language-disordered"
group (n
=
164),
45%
and
4.9
years
(SD
=
2.3).
A
follow-up
study of
the
same
sample
(Baker
&
Cantwell,
1987b)
revealed
that
the
overall
prevalence
rate
of psychiatric disorders
in
the
total
sample
of
speech- and
language-disordered children
had increased
from
44%
to
60%.
Diagnosis
of
Attention
Deficit
Disorder
(ADD)
and
Anxiety
Disorder
had
dou-
bled.
Over
the
5-year
period,
some
children
who
previ-
ously
had
been
diagnosed
"psychiatrically
well"
devel-
oped
psychiatric
disorders
including
Dysthymic
Disorder,
Separation
Anxiety
Disorder,
Oppositional
Dis-
order,
Adjustment
Disorder,
and
Avoidant
Disorder.
It
should be
noted
that
some
of
these
disorders
typically
have
a
later onset
in terms
of
their
natural
history.
Beitchman,
Nair,
Clegg,
and Patel
(1986)
conducted
an
epidemiological
study
of
1,655
five-year-old
kindergarten
children
in
Canada
who
were
assessed
for
speech
and
language
disorders.
They
found
11%
had
speech
and
language
disorders
and,
of
these,
48.7%
presented
with
a
psychiatric
disorder
as
well
as
a
speech
and
language
disorder. In
England,
Stevenson
and
Richman
(1976)
found
that
59%
of
3-year-old
children
with
expressive
language delays
had behavioral
disturbances. Finally,
in
an
ongoing
study
in our
setting,
38
of
55
consecutive
admissions
(67%)
to
a
children's
inpatient
unit
failed
a
speech
and
language
screening
upon
admission.
It
is
important
to
note
that
none
of
these
children
had
signif-
icant
cognitive
deficits
or
pervasive
developmental
disor-
ders.
Thus,
a
high
rate
of
co-occurrence
of
speech-lan-
guage
disorders
and
emotional
and behavioral
disorders
in
children
and adolescents
has
been
documented
in
numerous
studies
in
at
least
three
countries.
Baltaxe
and
Simmons
(19
88a)
published
a
literature
review
of
studies
of
pragmatic
deficits
in emotionally
disturbed
children
and adolescents
with
communication
disorders and
noted that
the
"domain
of
emotional
disor-
ders
has
only
begun
to
be
explored with
respect
to
iden-
tifying
pragmatic
disorders"
(p.
242).
Literature
regarding
children
with
psychiatric
disorders, behavioral disorders,
mental disorders,
and
psychopathology
was
reviewed,
and
seven
case
studies
were
presented.
Pragmatic
deficits
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182
Journal
of
Speech
and
Hearing
Disorders
noted
by
the
authors
included
nonlinguistic
as
well
as
linguistic
behaviors.
These
authors suggested that
when
pragmatic
development
is
viewed
as
the
interface of
four,
rather
than three, principal developmental
dimen-
sions
(i.e.,
linguistic,
social,
cognitive,
and
affective),
it
may
also
be
argued
that children
who
suffer
from
lags,
deficits,
or
disorders
in
emotional
development
may
be
at
risk
for
pragmatic
deficits.
(p.
226)
The
association
between juvenile
delinquency
and
learning disabilities
also
has
been
a
focus
of research
(Lane,
1980;
Wilgosh
&
Paitich,
1982).
The
significant
relationship
between
language
disorders and
learning
dis-
abilities
has
been
discussed
elsewhere
(Maxwell
&
Wallach,
1984).
Thus,
it
is
likely
that
these
research
stud-
ies
include
a
significant
proportion
of
language/learning-
disabled
subjects. Meltzer,
Roditi,
and
Fenton
(1986)
sug-
gested
that
various
subtypes of
delinquency
could be
differentiated. One
of
these
subtypes
is
unique
to
delin-
quency and possibly
reflects
a
group
of children's
behav-
ioral
and
social
problems
superimposed
on
specific
learn-
ing
profiles.
A
second
subtype displayed
cognitive
and
educational
profiles
virtually
identical
to
the
profiles
of
learning-disabled
adolescents.
A
third
subgroup
was
char-
acterized
by
learning
and
cognitive
profiles
similar
to
those
of
average
achievers.
The
authors
concluded
that
their
results "suggest
that
juvenile
delinquency
may
rep-
resent
one
possible
end
result
of
a
specific
learning
dis-
ability"
(p.
589).
They postulated
that
in
some
children
"learning
problems
and
behavioral disorders
may
occur
simultaneously;
in
others,
common
factors
may
contribute
to
both
learning
disabilities
and
juvenile
delinquency
and
...
learning
problems
may
often
lead
to
school
failure
and
low
self
esteem"
(pp.
589-590).
They
further
developed
this
model
to
state
that the
negative
self-image
can
con-
tribute
to
the
development
of
juvenile
delinquency.
Clearly,
speech-language
pathologists
need
to
become
familiar
with
the
relationship
between
communication
disorders and
psychiatric disorders because
a
significant
proportion
of
their
clients/patients
are
likely
to
experi-
ence
both.
As
will be
discussed,
knowledge of
this rela-
tionship
may
have
a
direct
influence
on
differential
diag-
nosis,
contexts
and
content
of
treatment,
and
service
delivery
and
educational
placement
considerations.
Types
of
Psychiatric
Disorders
in
Communicatively
Disordered
Children
and
Adolescents
Researchers
have only
recently
addressed
issues
of
the
types of psychiatric disorders
found
in
communicatively
disordered children
and
adolescents.
Some
types
of
psy-
chiatric
disorders
have
been
found
to
occur more often
in
the
speech-
and language-impaired population.
Baker
and Cantwell
(1987a)
identified
two
major
groupings
of
psychiatric disorders
in
DSM
III
(APA,
1980) as
being
strongly
associated with
communication disorders: be-
havior
disorders
and emotional
disorders.
These
are
dif-
ferentiated
on
the
basis
of
behavioral
symptoms.
Chil-
dren
and
adolescents
with
behavior disorders frequently
exhibit
overt behaviors
(e.g.,
overactivity, aggression)
that
disturb the environment
and
people
nearby.
This
cate-
gory
includes
Attention Deficit
Hyperactivity
Disorder
(ADHD),
Oppositional
Disorder,
and
Conduct
Disorder.
Children
and
adolescents
with
emotional
disorders
may
experience
internalized
and/or
somatic
symptoms
that
do
not
directly
disrupt
the
environment.
This
category
in-
cludes
Anxiety
Disorders,
phobias, and
forms
of
depres-
sion.
Diagnoses
of emotional
disorders
and
behavioral
disorders
are
not
necessarily mutually
exclusive.
Beitchman,
Nair,
Clegg,
Ferguson,
and
Patel
(1986),
using
a
slightly different
breakdown,
found
that
two
of
three
psychiatric disorders
(i.e.,
Emotional
Disturbance,
Attention Deficit
Disorder) were
far
more
prevalent
in
speech-
and
language-impaired
kindergarten children
than
in
the
non-speech-language-impaired
control
group.
[Beitchman
et
al.'s
category
of'
Emotional
Disturbance
included
DSM
III
(APA,
1980)
diagnoses of
Avoidant
Disorder
and
Adjustment
Disorder. The reader
is
re-
ferred
to
DSM
III-R
(APA,
1987) for
updated
definitions
and
diagnostic
criteria
of
these
psychiatric
diagnoses.]
Table
2
presents
these
comparisons.
Cantwell and
Baker
(1985)
found
that
certain
types
of'
communication
disorders
were
associated
more
often
with
psychiatric
disorders
in
their
speech
and
language clinic
sample.
For
example,
disorders
of
language
expression,
comprehension, and processing
were
found
to
be
associ-
ated
more often
with
psychiatric
illness
than
speech
dis-
orders
alone. Factors
that
distinguished
the
psychiatrically
ill
speech- and language-impaired
children
from
the
psy-
chiatrically well speech-
and
language-impaired children
included
a
greater proportion
of
boys,
and
an
increased
incidence
of
psychosocial
stressors
and
non-language de-
velopmental disorders
(Baker
& Cantwell,
1987a).
When
Baker
and
Cantwell
(1987b)
reviewed
their
complete
find-
ings
in
their
5-year
follow-up
study
of
their
speech
and
language clinic sample,
they
found
that
95%
of the
chil-
dren
had
received speech and
language
remediation.
Speech
and
language
intervention
alone,
however,
was
not
found
to
prevent
later
development
of
learning
or
psychi-
atric
disorders
nor
did
it
ameliorate
the
learning
disorders
and/or
psychiatric
disorders
in
children
who
had
them
initially.
However,
Baker
and Cantwell
(1987b)
measured
only
the presence
or
absence
of
emotional/behavioral
symptoms
at
follow-up,
and not
improvement
in
frequency
or
severity
of
symptoms.
Thus,
possible
positive
effects
of'
speech
and
language
intervention
on
emotional/behavioral
TABLE
2.
Percentage
of
different types of psychiatric disorders
in
speech-
and
language-impaired
children
in
kindergarten
and
control
children
(Beitchman,
Nair,
Clegg,
Ferguson,
&
Patel,
1986).
Speech
and
language
Control
group
Psychiatric
disorder
impaired
(n
=
135)
(n
=
137)
Emotionally
disturbed
12.8
1.5
Attention deficit
disorder
30.4
4.5
Conduct disorder
5.5
6.0
55
179-192
May
1990
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PRIZANT
ET
AL.:
EmotionallBehavioral
Disorders
183
functioning cannot
be
ruled
out.
Substantial
improvement
was
noted
in
communication
skills.
Hypothetical
Models
of
Causality
There
is
sufficient
evidence
from
research and
clinical
practice
that
a
relationship
exists
between
communica-
tion disorders and
emotional/behavioral disorders;
how-
ever,
the nature
of this
relationship
remains
unclear.
At
least
four
hypothetical
models
dealing
with the
question
of
direction
of causality
are
suggested
in
the
literature
and/or
from
our
clinical practice.
The
first
hypothetical
model
stipulates
that
psychiatric
disorders
lead
to
communication disorders.
There
is,
however,
little
empirical
evidence
to
support
this
model.
Based
on
our clinical
practice,
questions frequently
are
posed concerning the
progression
of
specific
psychiatric
disorders
as
they
relate
to
language
development.
For
example,
a
child
diagnosed
with Attention-Deficit
Hyper-
activity
Disorder
(ADHD)
may
demonstrate
difficulties
in
maintaining sustained
attention
to
a
task
with
language
input
presented
auditorily.
It
is
conceivable
that
the
presence
of
these
difficulties
as
language
is
developing
may
lead
to
receptive
language
and
language-processing
deficits.
A
second
example
is
that
of
a
child
diagnosed
with
Dysthymic
Disorder,
a
form
of
depression.
The
presence
of
mood
disorders
in
young
children,
specifi-
cally
depression,
remains
a
controversial subject
(Rutter,
Izard,
&
Read,
1986).
However,
in
our
experience,
young
children
diagnosed with
Dysthymic
Disorder
often
have
limited
social
and
verbal interactions.
The
decreased
amount
of
social
and
verbal
exchange
could
limit
a
child's
language
and
social
experiences
during
the
early
stages of
language
development,
which
conceivably could lead
to
speech
and
language
delays and/or pragmatic
deficits.
The
second hypothetical
model
stipulates
that
commu-
nication
disorders
lead
to
psychiatric disorders
(Baltaxe
&
Simmons,
1988a).
This hypothesis
is
based
on
the
prem-
ise
that
communication
difficulties
lead
to
a
variety
of
psychosocial
deficits
that
may
be
mechanisms
for
the
development
of psychiatric
disorders.
Cantwell
and
Baker
(1980)
stated,
"It
is a
likely
hypothesis
that
a
handicap
in
the
development
of
speech
and
language
would
predispose children
to
the development
of
psychi-
atric
problems,
since
language
is
considered
to
be
one of
the
main
features
that
makes
us
human"
(p.
162).
For
example,
children
with
a
diagnosis
of elective mut-
ism,
which
is
classified
as
a
psychiatric
disorder
in
DSM
III-R,
often have
histories of
speech
and
language prob-
lems.
Wilkins
(1985)
compared
case
notes
of
24
children
diagnosed
as
electively mute
to
24
children
diagnosed
with
other
emotional
disorders. One
third
of
the
electively
mute
children
had
experienced delayed development
of
speech,
but
none
of the
matched
controls
had
experienced
such
delays.
Thus,
it
is
conceivable
that
delays
in
speech
and
language
development
may
be
a
major
factor
in
the
development
of elective
mutism
for
many
children.
Baker
and Cantwell
(1982b)
found
that
almost
half
of
the
speech-
and
language-impaired
children
first
referred
to
a
community
speech
and language clinic
had
some
psychiatric
illness
according
to
DSM
III
criteria.
As
noted, they found
that
children
presenting
with
a
disor-
der
of
language
comprehension
or
processing
were
most
seriously
at
risk
for
the
development
of
psychiatric
disor-
ders,
although
specific
psychiatric disorders were
not
clearly associated
with
specific
types
of
language
deficits.
Many
children
and adolescents
referred
to
psychiatric
facilities have
expressive
language
disorders
(Gualtieri
et
al.,
1983)
that
make
it difficult
for
them
to
fully express
their
ideas,
feelings,
fears,
and
needs.
Based
on our
experience,
this
group
is
representative
of
at
least
some
children
served
by
most
speech-language
pathologists
both within and
outside
of
mental
health
settings.
These
children
may
appear
to
be
immature
and restless,
and
may
develop
impulsive
and
aggressive behaviors.
Other
children
who
present
with language-processing
deficits
may
misinterpret
messages
and
are
unable
to
request
further
information
or
clarification,
resulting
in
confusion
and
frustration.
Consequently,
they
may
demonstrate
externalizing behaviors
(e.g.,
destroying
materials,
phys-
ical
confrontation with
peers
and
adults),
internalizing
behaviors
(e.g.,
withdrawing
from
interactions,
self-abu-
sive
behaviors),
or
both.
Research
has
yet
to
demonstrate
a
unidirectional
causal
relationship
between
communica-
tion
and
psychiatric
disorders. However, our
clinical
experience indicates
that
for
some
children
linguistic
modifications,
such
as
reduction
in
linguistic
complexity,
results
in
positive behavioral
changes,
suggesting
that
behavioral
and
emotional
problems
may
be
precipitated
and
perpetuated
by
difficulties
in communication.
The
third
hypothetical model
goes
beyond
unidirec-
tional
explanations
of
causality
between
communication
and psychiatric
disorders. Beitchman
(1985),
Baker
and
Cantwell
(1987a),
and
Baltaxe
and
Simmons
(1988a)
con-
sidered
the possibility
of
a
third
underlying
factor
causing
both communication
disorders and psychiatric disorders.
For
example,
Beitchman
attempted
to
examine
the
role
of
social
class
variables
both
on
language
impairment
and
psychiatric
disorders.
However,
the
independent
contri-
butions
of
social
class
could
not
be
determined due
to
its
multivariate nature.
Baker
and Cantwell
(1987a)
consid-
ered
common
antecedents
to
psychiatric
and
communica-
tion
disorders
including
low
IQ,
significant
hearing
loss,
organic
brain
damage,
adverse
family
conditions,
low
so-
cioeconomic
status,
and
significant
stress
in
childhood.
These
factors
have
been
found
to co-occur
with both
language
disorders
and
psychiatric disorders.
Intellectual
retardation, marked
hearing
loss,
and brain
damage
were
found
in
a
small
percentage
of
the
sample
but
did
not
account
for
the
differences
between
the
psychiatrically
well
and
the
psychiatrically ill
speech-
and
language-
impaired
groups.
Social
class
distributions were
not
found
to
be
significantly
different
between
the
two groups,
al-
though
an
association
between the
total
amount
of
all
types
of
psychosocial stress
and
the presence
of both
psychiatric
and
language
disorders
was
found.
Individual
family
fac-
tors
such
as
parental
mental illness
and
family
discord
did
not
occur
with
sufficient
frequency
to
test
for
statistical
significance (Baker
&
Cantwell,
1987a).
Baltaxe
and
Sim-
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184
Journal
of
Speech
and Hearing
Disorders
mons
(1988a)
noted
that
prenatal,
perinatal,
medical,
so-
cial,
and
family
history
of
a
child
may
include
significant
variables
that
play
a
role
in
the development of
a
commu-
nication handicap
as
well
as a
psychiatric disorder.
The
fourth
hypothetical
model,
the
transactional
model
(Sameroff,
1987;
Sameroff
&
Chandler,
1975),
addresses
more
specifically
the
mutual
influence
between
child
and
environment
from
a
longitudinal
and
developmental
per-
spective.
Sameroff
(1987)
stated,
"The
development
of
the
child
...
[is]
seen
as
a
product
of the
continuous
dynamic
interactions
of the
child and the
experience
provided
by
his/her
family
and
social
contacts"
(p.
278).
The child
and
the
environment
are
therefore
interdepen-
dent.
According
to
Sameroff
(1987),
the
characteristics
a
child
displays
at any
point
in
time
are
never
a
function of
the individual
alone
or
the experience
itself,
and
viewing
a
child's development
in
this
way
is
misleading.
For
example,
a
child
who
is
born
with
a
very
low
birthweight
(VLBW)
(i.e.,
<1500
g)
and
is
medically
fragile,
may
cause
maternal
anxiety.
The
mother's
anxiety
and
the
child's
fragile
condition
could lead
to
interactive distur-
bances
(e.g.,
avoidance
or
excessive
intrusion).
Conse-
quently, the
child
may
develop
a
difficult
temperament
that
would
continue
to
negatively
affect
mother/child
interaction.
This
may
reduce
the
amount of interaction
the
mother
has
with
the
child
and,
over
time, this
lack
of
stimulation could
result
in
a
language delay.
McCauley and Swisher
(1987)
reviewed
the
literature
on
maltreatment
and
speech
and
language
impairment.
They
found
evidence
for
a
relationship between
neglect
and receptive
and
expressive
language disorders.
Their
discussion
exemplifies
a
transactional
process
in
that they
suggested
that
speech
and language disorders
may
lead
to
neglect, which
may
result
in
later
emotional
or
behavioral
problems
in
children.
Finally,
it
is
conceivable
that
there
is
no
causal
rela-
tionship
between
communication disorders and
psychiat-
ric
disorders
in
specific
cases.
For
example,
a
child
may
present
with
a
lateral
lisp.
This child
may
also
may
have
a
diagnosis
of
thought
disorder.
It
seems
highly
unlikely
that the
presence
of
these
two
disorders
is
related.
The
differences in
these
hypothetical
models
underscore
the
complexity
of
the
issue
of
causal
relationships.
It
is
probable
that
not
any
one
hypothetical model
could
account
for
all
cases
of relationships
between
communication
disor-
ders
and
psychiatric disorders.
Significant
variables
could
include
the
following:
the
nature
of precipitating
factors
(e.g.,
biological and/or
environmental),
age(s)
of
exposure
to
precipitating
factors,
the
presence
of
psychosocial
supports
(e.g.,
family
support)
or
other
protective
factors
that
may
reduce
the
likelihood
of
the
development
of
a
communica-
tion and/or
psychiatric
disorder,
and temperamental/person-
ality
characteristics
of
the
affected
child.
In
summary,
the
presence
of
emotional
and/or
behav-
ioral
disorders
is
now
acknowledged
to
be
a
concomitant
problem
for
many
children
and
adolescents
with
commu-
nication disorders.
Although
specific
relationships
among
these
disorders
remain
to
be
clarified,
there
is
little
doubt
that
speech-language
pathologists
have
the
opportunity
to
play
an
important
role
in
serving
this
population.
PRACTICAL
ISSUES
FOR
SPEECH-LANGUAGE
PATHOLOGISTS
In
practice,
speech-language
pathologists
must deal
with
the
challenges
posed
by
children
and
adolescents
with communication
disorders and emotional/behavioral
disorders.
These include
differential diagnosis,
early
identification
and
prevention,
and
intervention.
Speech-
language pathologists
must
clearly
define
their
role
in
serving
this
population and
meet the
challenge
of provid-
ing
appropriate
services
in
different
settings.
Differential
Diagnosis
The
overlap
of
symptomatology
in
communication
and
psychiatric
disorders
raises
important questions
and
chal-
lenges
related
to
accurate
diagnosis
and
appropriate
treat-
ment.
One
challenge in
making
an
accurate
diagnosis
is
that
of
differentiating communication
disorders and
psy-
chiatric
disorders
considering
overlap
in
symptomatology.
Another
challenge
is
interpretation of assessment
results.
These
challenges
are
not necessarily mutually
exclusive.
It
is
often
difficult
to
determine
the
origins
of
behavioral
and
emotional
difficulties
observed
in
these
children
and
adolescents.
Frequently, children
and
adolescents
with
communication
disorders
demonstrate
behavioral
diffi-
culties
that
are
thought
to
have
a
psychiatric
basis.
For
example,
a
child
may
refuse
to
participate
in
group inter-
actions,
appearing
to
be
antisocial
or
oppositional.
Assess-
ment
of
receptive
language
skills may
reveal
significant
deficits.
Thus,
antisocial reactions
may
be
best
understood
in
reference
to
the
communication
impairment
in
situa-
tions
with
significant
linguistic
and
social
demands.
Speech-language pathologists
frequently
evaluate
chil-
dren
in
whom
Attention-Deficit Hyperactivity
Disorder
(ADHD)
is
questioned.
In
a
classroom context,
these
children
are
easily
distracted,
have
difficulty
following
instructions, and
do
not seem
to
listen
to
what
is
being
said
to
them
(DSM
III-R,
1987).
A
speech
and
language
evaluation,
including
observations
across
situational
con-
texts,
should
address
the question
of whether
these
be-
havioral difficulties
may
be
the
result
of
language-pro-
cessing
deficits.
For example,
if
symptoms
noted
above
are
observed
during
verbal
tasks
demanding
attention
to
linguistic
input,
but
not
during
activities
or tasks
with
fewer verbal
demands,
specific
language-processing
def-
icits
may
be
suspect.
However,
if
symptoms
are
noted
consistently
across
activities
and
contexts
regardless
of
verbal
input,
there
is
greater
evidence
for
ADHD.
Of
course,
naturalistic
observations
should
always
be
consid-
ered
along
with
evidence
from
more
formal
assessments.
Although
the
above
examples
imply
mutually
exclusive
disorders,
this
is
not
the
case
for
many
children
and
adolescents
displaying emotional/behavioral
difficulties
and communication
problems.
More
frequently,
we are
concerned
with
the
degree of
contribution
of
each
on
a
child's
daily functioning.
For
example,
school-age
chil-
55 179-192
May
1990
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PRIZANT ET
AL.:
Emotional/Behavioral
Disorders
185
dren
who
present
with emotional/behavioral
difficulties
frequently
have
a
history of
school
failure and poor
peer
relationships.
A
speech
and
language evaluation
may
reveal significant
receptive
and
expressive
language
def-
icits.
It
is
plausible
to
assume
that
a
transactional
process
is
operative;
that
is,
constitutional
factors
interacting
over
time with
environmental
factors
contribute
to
the
diffi-
culty
these children
experience.
If
appropriate
therapeutic
strategies
are
to
be
devel-
oped,
all
aspects of
the
child's
development,
as
well
as
the
reaction
of
the
environment
to
the
child,
need
to
be
considered
in
differential
diagnosis.
In
order
to
do
this,
an
assessment
of
the child's current
status
and
review
of
medical and
developmental
history
is
required.
Mental
health
professionals
recognize
the
need
for
a
careful
multidisciplinary
examination of
various
factors
(i.e.,
bi-
ological,
psychological,
social)
that
may
contribute
to
an
individual's
functioning. However, doing
so
is
often
dif-
ficult
for
a
number
of
reasons.
First,
factors
to
be
consid-
ered
are
many
and diverse.
Biological
factors
may
include
genetic
factors,
perinatal
history, sensory
impairments,
allergies,and
past and
recent
illnesses.
Psychological
fac-
tors may
include
cognitive
status,
academic performance,
and
personality
characteristics
such
as
self-esteem.
Social
factors
may
include
family
composition,
socioeconomic
status,
peer
relationships,
and
cultural
factors.
Second,
the
multidisciplinary
process
may
be
compli-
cated
by differences
in
theoretical
frameworks
under
which
professionals operate. Gualtieri
et
al.
(1983),
a
child psychiatrist
and
his colleagues
working in
a
psychi-
atric
setting,
emphasized
the
need
for
professionals
work-
ing
with this population
to
develop
a
thorough
under-
standing
of
developmental
problems,
especially
in
language
and
communication.
Such
knowledge
is
critical
in
formulating
accurate diagnoses
and appropriate
treat-
ment
plans
for
children
with
emotional
or
behavioral
disorders
and communication
disorders.
A
speech
and
language
assessment
often
provides
essential
information
for
understanding
children's
behavior,
formulating
treat-
ment
approaches,
and
explaining
a
child's
behavioral
and
communication
difficulties
to
others.
Gualtieri
et
al.
stated that
no
psychiatric
diagnosis
is
appropriate
in
a
severely
dis-
turbed
child until
a
thorough
developmental
assessment
is
in
hand.
Language
assessment
is
an
essential
part of
this
because
the
information
provided
...
has
a
profound
effect
on
one's
understanding
of
behavioral
symptoms,
the
treatment
thereof, and
the interpretation
of the
child's
problems
to
parents,
teachers and
other
caretakers.
(p.
168)
Gualtieri
et
al.
noted that
speech-language pathologists
frequently
are
more
aware
of
psychiatric disorders
in
their
clients
than
psychiatrists
and
psychologists
are
of
speech
and
language
disorders
in
theirs.
The
second challenge,
interpretation
of
assessment
results,
may
be
problematic because
most psychological
or
psychiatric
assessment
tools
are
language
based.
Gual-
tieri
et
al.
(1983)
questioned
the
validity
of
such
instru-
ments
for
children
with
language
impairments.
Lan-
guage-impaired
children frequently appear
disorganized
and agitated in
unstructured
verbal
situations.
These
behaviors
may
appear
to
be similar to
characteristics
of
"borderline"
or
"psychotic"
behavior.
When
language-
processing
demands
are more
appropriate,
a
different
clinical
picture
may
be
observed.
It
is
important
for
mental
health
professionals
to
understand
a
child's
devel-
opmental level
and,
in
particular, communication
skills,
if
appropriate
psychotherapeutic
strategies
are
to
be
imple-
mented.
Too
often,
verbally
based
assessments
or
psycho-
therapies
assume
a
child's
normal
understanding
and
use
of
language.
Deviant
language
skills
could
lead
to
misin-
terpretations
of
information
a
psychotherapist
would
ob-
tain
during remediation. Without
integrating
knowledge
of
a
child's
language
functioning,
diagnosis
may
be
inac-
curate,
and
the
resulting
treatment
plan
addressing
emo-
tional and
behavioral
issues
may
be
inappropriate.
Early Identification
and
Prevention
Ideally,
primary
prevention
would
be
the
strategy
of
choice
in
working
with
young
children
who are
at
risk
for
emotional
and
behavioral
disorders and/or speech,
lan-
guage,
and
communication
disorders.
Primary
prevention
has
been
defined
by
the
ASHA
Committee
on
Prevention
of
Speech, Language,
and
Hearing
Problems
as
"the
elimination
or
inhibition
of
the
onset
or
development
of
a
communication
disorder
by
altering
susceptibility
or re-
ducing
exposure
for
susceptible
persons"
(ASHA,
1988,
p.
90).
If
parents with
at-risk
children
are
provided
with
appropriate
information
and
social
supports
for
fostering
their
children's
emotional, cognitive,
and
social/commu-
nicative
growth,
it
may
be
possible
to
preclude
the
development
of psychiatric
or
communication disorders.
This
would
demand that
all
aspects of
development
be
attended
to
from
very
early
on,
especially
by
profession-
als
who
may
be
responsible
for
care
of
very young
children
(e.g.,
pediatricians,
day care
staff).
Special
atten-
tion
should be
paid
to
children
who
are
at
high
risk
for
the
development
of emotional
and behavioral problems
and
communication
disorders
(Baker
&
Cantwell,
1984).
Cantwell
(1987)
noted
that
risk
factors
for
the
develop-
ment
of
communication and/or
psychiatric disorders
in-
clude
the
presence
of
cognitive
impairment,
sensory
impairments,
central
nervous system
dysfunction,
ad-
verse
family
conditions,
low
socioeconomic
status,
psy-
chosocial stress,
parental mental illness, perinatal
com-
plications, and
premature
birth.
These
factors
are
not
mutually
exclusive,
and
no
one
factor
is
highly
predictive
of
the development
of
psychiatric
and/or communication
disorders. However,
young
children
who
have
multiple
factors
associated
with
their
early
developmental
experi-
ences
tend
to
be
at
higher
risk
for
the
development
of
emotional
and behavioral disorders,
especially
in
the
presence
of
a
communication
disorder
(Cantwell,
1987).
Thus,
screening
to
identify
children
who
are
at
risk
due
to
the
presence
of
these
factors
must
occur
if
preventative
steps
are
to
be
taken.
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186
Journal
of
Speech
and
Hearing Disorders
Secondary
prevention
of
emotional
and
behavioral
dis-
orders in
children
may
be
possible
through
early
identi-
fication
of
communication disorders with
subsequent
appropriate
referral. Secondary
prevention
has
been
de-
fined
by
the
ASHA
Committee
on
Prevention
of
Speech,
Language,
and Hearing
Problems,
as
"the
early
detection
and
treatment of
communication disorders.
Early
detec-
tion
and
treatment
may
lead
to
the
elimination
of
the
disorder
or
the
retardation
of the
disorder's
progress,
thereby preventing
further
complications"
(ASHA, 1988,
p.
90).
Recent
literature
on
prelinguistic
and early
lan-
guage
development
(Bates,
O'Connell,
&
Shore,
1987)
has
suggested
that
early
identification
of
communication
disorders
in
children
can
begin
prior
to
the
expected
acquisition
of
first
words.
Wetherby and Prizant
(1988)
and
Paul
(1987)
advocate
the
assessment
of
prelinguistic
communicative behaviors
known
to
be
predictive
of
later
language
acquisition
to
ascertain the
presence
or
absence
of
a
communication
delay.
Certainly,
an
attitude of
"let's
wait
and
see"
is
no
longer acceptable
for
young
children
suspected
of
having
a
communication impairment, espe-
cially
considering
current
efforts to
provide
services
for
the
0-2
population
as
outlined
in
Public
Law
99-457.
Referral
for
full
developmental
evaluations
should
be
made
if
there
is
any
suspicion
of
developmental
delay.
Specific
referral
for
a
communication
evaluation should
occur
if
there
are
concerns
specific
to
the
area
of
commu-
nication
development.
Current
philosophies
of
early
intervention
focus
on
the
family
unit
as
the
primary
context
for
intervention
and
caregivers
as
the
primary
intervention
agents
(National
Center
for
Clinical Infant
Programs,
1985).
Public
Law
99457
stipulates
that
an
Individualized
Family
Service
Plan
must
be
developed
for
the
0-2
population
in recog-
nition
of the
significant impact
of
a
disability
on
the
family
and the central
role
of
caregivers
in
treatment.
Thus,
providing
caregivers
with
information
to
help
them
interact
with and
respond
effectively
to
their
young
chil-
dren
is
an
essential
aspect
of
early
intervention.
As
caregivers
develop
greater
confidence in facilitating
the
development
of communication
skills,
they
become
em-
powered
to
take
a
major
and
active
role in
their
child's
treatment
(Girolametto,
Greenberg,
&
Manolson,
1986;
Prizant
&
Tiegerman,
1984).
Identification
and
prevention
also
are
important
issues
for
older children
and
adolescents.
Current
experience
in
our clinical
setting
and
that
reported
in
other
settings
for
children
with
emotional
and
behavioral disorders
(Cant-
well,
1987)
indicate
that
many
children
and
adolescents
with
more
subtle
communication disorders
often
are
not
identified. Cantwell
(1987)
estimated
that
approximately
50%
of
the children
and
adolescents
admitted
to
the
inpatient
units
at
the
Neuropsychiatric
Institute
at
UCLA
have
communication disorders,
and
of
those,
approxi-
mately
40%
had
not
been
diagnosed
as
having
a
commu-
nication
disorder
prior
to
admission
for
emotional
and/or
behavioral disorders.
Children
with
significant
behav-
ioral
disorders
who
also
experience
communication
dis-
orders
from
early in
the
school years
often
are
not
iden-
tified
as
having
communication
disorders.
They
may be
placed
in
classes
for
the
"behaviorally
disordered"
or
"emotionally
disturbed,"
and
because
symptomatology
of
emotional
or
behavioral
disorders
are
most
striking
or
of
primary concern,
more
subtle
communication problems
that
may
be
involved
directly
in
the
development
and
perpetuation
of
the
behavioral
and/or emotional
disorder
may
be
overlooked.
This
has
been
our
experience
in
serving
children
from
public
school
settings.
Problems
that
go
undetected
include
more
subtle
lan-
guage-related
deficits
such
as
comprehension
problems,
or
subtle
expressive
deficits
such
as
word-retrieval
or
formulation
problems,
rather
than
more
obvious
fluency
or
articulation
problems.
Camarata
et
al.
(1988)
adminis-
tered
the Test
of Language
Development-Intermediate
(TOLD-I)
(Hammill
& Newcomer,
1982)
to
38
children
(age
range:
8.9-12.11;
M
=
10:11,
SD
=
1.21
years)
in
a
public
school
setting
identified
as
having mild/moderate
behavioral
disorders
who
were
mainstreamed
for
one
or
more
courses.
For
27
(71%)
of the
subjects
at
least
one
of
the
TOLD-I
subtest
scores
fell
two
or
more
standard
deviations
below
the
normative sample,
and
for
10
sub-
jects
(26%)
at
least
one
of
the
subtest
scores
fell
between
1.0
and
2.0
standard deviations
below
the
normative
sample.
A
case
file
review
indicated
that
none of
the
subjects
had
received
a
formal
language
assessment,
and
only
2
of
38
(fewer
than
6%)
had
ever
been
seen
for
services by
speech-language pathologists.
Based
on
these
findings, Camarata
et
al.
concluded
that
speech
and
language
assessment
"should
become
a
routine
portion
of
the
management
program
for
BD
children"
(p.
198).
Thus,
ongoing
identification
is
essential
to
provide
appro-
priate
services
for
children
and adolescents
who
may
be
"missed"
early
in
the
school years.
Intervention
With
identification
of
a
communication
disorder
and
related
emotional and/or
behavioral
sequelae,
interven-
tion
must be
based
on
a
multidisciplinary
model
with
coordinated
planning.
Aspects
of
a
child's
development
and adaptive
functioning should
be viewed
in
reference
to
psychological,
biological,
and
social
variables
noted
earlier.
A
thorough
family,
medical, and
developmental
history
is
necessary
to
identify
such
factors.
Other
factors
to
consider
include
a
child's tendency
to
externalize
reactions
to
psychosocial stressors,
which
may
result
in
aggressive
or
oppositional behavior,
or
to
internalize
reactions,
which
may
be
manifested
in
significant
anxiety,
social
withdrawal,
and/or
depression.
All
these
variables
must be
taken into
account
in
therapeutic
and
educational
planning
if
treatment
is
to
be
coordinated, thorough,
and
relevant.
Once
a
treatment
plan
is
developed,
incorporating
information
from
biological, psychological,
and
social
assessments,
it
must include
a
means
for
monitoring
improvement
in one area
(e.g.,
behavioral
or
emotional
status)
in
reference
to
improvement
in
other
areas
of
development
(e.g.,
communication). Once
again,
ongoing
interaction
of
professionals
with
specific
expertise
in
55
179-192
May 1990
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PRIZANT
ET
AL.:
EmotionallBehavioral
Disorders
187
these
dimensions
of
development
assures
that
important
changes
will
not
be
overlooked.
Speech-language
pathologists
must be
aware
that
the
co-occurrence
of communication disorders and emotion-
al/behavioral
disorders
in
children
may
have
a
significant
impact
on
therapeutic
strategies and
the content
and
contexts
of
treatment
(Prizant
et
al.,
1988).
For
example,
developing
trustful
therapeutic
relationships
with
these
children
and
adolescents
may
be considerably
more
dif-
ficult
than
with
speech-language-impaired children
with-
out
emotional/behavioral
disorders.
Additional
complex-
ities
may
arise
in
working with
disorganized
families,
determining
truly
functional
goals
across
environments,
and coordinating
efforts
with
other
professionals. Speech-
language
pathologists
must
be
capable of
identifying
and
understanding
these
challenges,
and
of generating
cre-
ative
solutions
toward
meeting them
(Prizant
et
al.,
1988).
Defining
the
Role
of
Speech-Language
Pathologists
Professionals
in
speech-language
pathology must
be-
come
effective advocates by
informing
others of
the
relevance
and
value
of
our
services
for
this
population.
However,
appropriate training
for
serving emotionally
and
behaviorally
disordered children
and adolescents
is
typically
limited
in
communication
disorders
training
programs.
In most
undergraduate
and
graduate
course-
work,
little attention
is
given
to
issues of
emotional
and
behavioral disorders
in
children
and
adolescents.
This
information
is
lacking
at
a
theoretical
level,
where
stu-
dents
in our
profession
receive little
exposure
to
the
extensive
literature
available,
and
at
a
practical
level,
where
practicum
experiences
are
rarely
provided
in
men-
tal
health
settings. Thus,
students
or
trainees
have
little
opportunity
to
interact
on
a
regular
basis
with
mental
health
professionals
such
as
clinical
psychologists,
social
workers,
and
child
psychiatrists and
are
rarely
exposed
to
a
treatment
team
model,
which
is
commonly
used
in
mental
health
agencies
and
is
an
absolute
necessity
for
providing appropriate
services. Professionals
in
our
field
also
rarely
are
exposed
to
or
trained
in
the
use
of
DSM
III-R
(APA, 1987).
Lack
of knowledge of
DSM
III-R
as
a
conceptual
framework
for
understanding
emotional
and
behavioral disorders,
and
limited
understanding
of
its
terminology,
creates
a
significant obstacle
for
speech-
language pathologists
who
may
need
to
communicate
with mental
health
professionals
around
specific
cases.
This
information
should
be
made
available
at
training
levels
to
professionals
in
speech-language
pathology
and
audiology
if
we
are
to take
our rightful
place
within
the
continuum
of mental health
services.
With
a
working
knowledge of
emotional
and
behavioral
disorders
in
children
and
adolescents,
the potential
role
of speech-language
pathologists
becomes central and
is
multidimensional
in
nature.
Due
to
the
fact
that
a
high
percentage
of
children
referred initially
for
speech,
lan-
guage,
or
communication
disorders
also
experience
some
form
of psychiatric
disorder
(Cantwell
&
Baker,
1985),
it
is
incumbent
upon
professionals
in
our
field
to
develop
a
network
for
referral
to
mental
health
professionals
and
agencies. This
network
should
include
individuals
or
agencies
who
are
capable of
dealing
with
person-specific
therapeutic
issues
as
well
as
family
issues.
If
a
child
or
adolescent referred
for
speech and
language
services
demonstrates
symptomatology
of
emotional and behav-
ioral
disorders,
appropriate
referral
should not be
de-
layed.
If
the
child
or
adolescent
is
in
treatment
for
both
a
communication
disorder
and emotional/behavioral
disor-
ders,
treatment
should
be
coordinated
to
the
greatest
extent possible. Isolated
therapeutic
approaches
typically
do
not
address
the
transactional
nature
of
the
develop-
ment
and
perpetuation
of communication and emotional/
behavioral disorders.
Early identification
of both communication disorders
and
possible
emotional and
behavioral disorders
is
an
important function
of speech-language
pathologists.
Ad-
ditional
risk
factors
for
the
development
of
a
psychiatric
disorder
(noted
earlier)
should
be
taken
into
consider-
ation
when
evaluating
the
urgency
of
identifying
a
child
and referring
for
appropriate mental
health
services.
Once
children
are
identified
as
having
a
significant
com-
munication
impairment, the
role
of
the
speech-language
pathologist
shifts to
remediation
that,
in
many
cases,
may
have
a
positive
impact
on
emotional
and behavioral
problems.
Tracking
changes
in
both communication
abil-
ities
and
emotional
and behavioral problems with the
assistance
of
mental
health
professionals
could
provide
important
information
about
the
effect
of
improvement
in
communication
on
the
emotional
or
behavioral
disorder
and
vice versa.
Our
clinical
experience
suggests
a
direct
positive correlation
between
improvement
in
communi-
cation
and
improvement
in emotional
and
behavioral
problems.
Empirical
evidence
for
this
relationship
has
been
found
in
social
and cognitively
impaired
popula-
tions
(Carr
&
Durand,
1985;
Prizant
&
Wetherby,
1987).
Finally,
another important aspect
of
the
role
of speech-
language pathologists
is
to
educate
caregivers
and
other
professionals
to
provide
a
more
holistic
approach
to
children
with communication and
emotional/behavioral
disorders.
A
holistic approach
refers
to
an
approach that
considers
the
psychological,
biological,
and
social
aspects
of
a
child's
development
in
assessment
and intervention.
It
is
not
uncommon
to
find
communication
problems
being interpreted
as
an
outgrowth
or
manifestation
of
psychiatric
disorders
by
mental
health
professionals. For
example,
a
child
with
limited
speech
who
also shows
evidence
of
depression
may
be
viewed
as
minimally
verbal
because
of
the
depression. This
may
occur
because
mental
health
professionals
are
rarely
educated
in
com-
munication
disorders
of
children
and
adolescents.
Speech-language pathologists
must
inform
other
profes-
sionals
and
caregivers
that
communication
disorders
fre-
quently
co-occur
with
emotional
or
behavioral disorders,
may
not
simply
be
a
manifestation of them, and
may
actually
be
a
precipitating
factor
in
some
cases.
Addition-
ally,
because
of
the
close
interrelationship between
the
development
of
communication
disorders
and emotional
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188
Journal
of
Speech
and
Hearing Disorders
and
behavioral
disorders,
these
problems
should
not
be
treated
in
an
isolated
and
fragmented
manner
by
different
professionals.
It
is
not
uncommon
for
special
education
curricula
to
include
mutually
exclusive
behavior
manage-
ment
and
language
development
programs,
with
little
consideration
of
the
mutual
interdependence
between
the
two.
A
fragmented
isolated
approach
does
not
reflect
developmental
realities
and
often
results
in
conflicting
approaches
to
treatment. These
problems
can
be
avoided
through
an
understanding
of
the
relationships
between
the
communication
and emotional and behavioral prob-
lems,
and it
is
largely
the
obligation
of speech-language
pathologists
to
convey
this
information.
Issues
Specific to
Different Settings
The
challenges
faced by
speech-language
pathologists
vary
according
to
the
setting
in
which
they
practice.
These
settings
may
include
psychiatric
facilities,
commu-
nity mental
health
clinics,
speech
and
language
clinics,
schools
(including
regular
and
special
education),
pre-
schools
and
day
care
centers,
and developmental
pediat-
ric
and hospital
follow-up
clinics.
In
our
experience,
the
challenges
are
many and
varied
and
range
from clarifica-
tion
of
our expertise
(e.g.,
we
do
not
treat
just
articulation
disorders!)
to
informing
other
professionals
that
we
do
have
a
role
with this
population.
In
psychiatric
facilities,
speech-language
pathologists
typically
play
a
minimal
role
on
the
staff
or
may
function
as
consultants
on
a
part-time
basis.
Our experience
in
a
child
and
adolescent
psychiatric
center
suggests
that
other
mental
health
professionals
including
child
psychi-
atrists,
clinical
psychologists,
social
workers,
and
child
psychiatric
nurses
typically
have
minimal
if
any experi-
ence
in
working
with professionals in
speech-language
pathology.
Prior
to
the
growth
of the
department
in
our
setting,
the
role
of speech-language
pathologists
was
viewed
primarily
as
ancillary
service;
that
is,
serving
children
and adolescents
who have
easily
observable
speech
problems
including
articulation disorders,
fluency
disorders and
voice
disorders,
or
severe language
disor-
ders.
Because
the
majority
of
children
with
communica-
tion
disorders and
emotional/behavioral disorders
expe-
rience
less
obvious
language-based
disorders and thus
often
were
not
referred
for
services,
the
role
of
speech-
language pathology
was
not
viewed
as
significant.
Through
regular
in-service
training
and
a
constant edu-
cational
dialogue
in
evaluation
conferences
and
treat-
ment
team
meetings,
a
process
of "consciousness raising"
has
occurred
regarding
our professional
expertise, result-
ing
in
significant
increases
in
referrals
for
evaluation
and
requests
for
services
and
in-service
training. Clinicians
now
participate
in
inpatient
"community
meetings,"
group
psychotherapy,
outpatient
mother-toddler
groups,
an
infant
behavior
clinic
addressing relationship
disor-
ders, and
family
therapy.
In
all
these
cases,
referrals
are
primarily
for
emotional, behavioral,
or
interactive
distur-
bances. Additionally,
more
specific
questions
are
now
being
asked
by
mental
health
professionals
regarding
differential diagnosis and
appropriate
treatment
methods.
Furthermore,
in
our
setting,
the
position of viewing
a
communication
disorder
primarily
as
a
manifestation
of
a
psychiatric
disorder
has
been
modified
to a
great
degree.
For
example,
referrals
for
full
evaluations
from
mental
health
professionals
from
three
acute
care
inpatient
units
serving
children
and adolescents
increased
from
11%
to
56%
of
admissions
after
a
speech-language
pathologist
with
expertise
in
language-base
learning
disabilities
started
to
serve
those units
on
a
regular
basis.
Addition-
ally, an
understanding
of
communication
disorders
in
this
population
is
crucial in
psychiatric settings
because
ther-
apeutic
approaches
often are
verbally based.
Mental
health
professionals
in
psychiatric
facilities
must
under-
stand
the
nature and
the
impact
of
communication
disor-
ders
on
an
individual's
ability
to
participate
actively
in
dialogue.
Without
this
understanding,
it
is
likely that
purely
language-based
therapies
with
language-impaired
children
will
be
of limited
value and
may
even
be
inappropriate and
detrimental
to
therapeutic
processes.
Mental
health
professionals
in
community mental
health
clinics
often
have
the
same
lack
of
expertise
in
speech and
language,
as
do
many
staff
in psychiatric
facilities. Referrals
to
these
clinics
are
primarily
for
emo-
tional,
behavioral,
and
family
problems; thus, speech-
language
pathologists
traditionally
have
not had
a
role
in
community
mental
health
clinics
as
they
have
developed.
Infrequently,
a
speech-language
consultant
may
be
on
the
staff
of
a
community
mental
health
clinic; however,
without
the
constant
presence
and
ongoing in-service
education
about
the
expertise and potential
role
of
speech-language
pathologists,
services
may
be
provided
episodically
through
outside
referrals
for
evaluations.
Professionals
in
speech-language
pathology,
especially
those
who
are
beginning
to
develop
or
who
have
private
practices,
may find
community
mental
health
centers
to
be
a
great
resource
for
services following
appropriate
in-service
work
and education regarding
communication
disorders and
emotional/behavioral disorders. For
school-
age
children,
coordination
with
school-based
services
is
essential.
Conversely, community
based speech
and language
clinics
may
deal
primarily with communication
issues
and not
interact
closely
with
mental
health
professionals
around
issues
related
to
emotional
and
behavioral
disor-
ders,
or
even language-related
learning
problems.
Staff
in
these
clinics
may
have
little experience
with
or
knowl-
edge
about
emotional/behavioral disorders.
As
noted
ear-
lier,
the
studies of
Baker
and Cantwell
(1987b)
found
that
60%
of
their
sample of
600
children
referred
to
a
commu-
nity
speech and
language
clinic
experienced
diagnosable
psychiatric disorders.
Without
the
regular
input
of
mental
health
professionals,
many
children
experiencing
emo-
tional
and
behavioral problems,
or
who are
at
high
risk
for
such
problems,
may
not
be
referred
further. The
devel-
opment
of
a
network
for
mental
health
consultation
would
thus
play
a
vital role in
assuring
that
the needs
of
these
children
and
adolescents, and
their
families,
are
met.
Some
sensitivity
to
these
issues
is
being
demonstrated
in
55
179-192
May 1990
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PRIZANT
ET
AL.:
EmotionallBehavioral
Disorders
189
our
profession
as
evidenced
by
the
growing
attention
and
recent
reemphasis
on
the
importance
of
counseling
in
the
field
of
communication disorders
(Bloom,
Johnson, Bitler,
&
Christman,
1986;
Luterman,
1984;
Rollins,
1987)
and
the
significant role
of
the
family (Andrews
&
Andrews,
1986).
Although
some
counseling
services
regarding
com-
munication
disorders
may
not
directly
address
the
issue
of
emotional
and
behavioral disorders,
counseling
is
a
positive
step
toward recognizing
the
need
for
supportive
therapies
in
addition
to
therapy
for
treating
the
commu-
nication
disorder.
As
noted
earlier,
many
children
and adolescents
with-
out significant
developmental
disabilities,
who
are
re-
ferred
to
our
facility
from
regular and
special
education
services, have
undiagnosed
communication
disorders.
Typically,
these
individuals
had
been
identified
or
"la-
beled"
as
emotionally
disturbed
or
behaviorally
disor-
dered
early
in
their
school
career.
Because
of this
ten-
dency
to
separate
issues
of
behavior
from
communication,
it
is
not
uncommon
for
a
child's
communication
needs
to
be
overlooked
if
the
priority
is
on
dealing
with
emotional
or
behavioral
problems.
This
is
especially
true
in
school
settings
where
speech-language
pathologists
have
high
caseloads.
Information
about
the
co-occurrence
of
these
problems
is
essential
for
schools
to
play
an
appropriate
role
in
meeting
all
the
needs
of
children
experiencing
multiple
problems.
Speech-language
pathologists
currently
are
becoming
more
involved
in
settings
serving
infants
and
toddlers
that
provide
opportunities
for
prevention
and
early
inter-
vention
services. Preschool and
day
care
settings
are
important
contexts
for
taking
preventative
measures
through
parent
and
staff
education, and
for
identifying
and
referring
those
children
who
are
demonstrating
com-
munication
and/or emotional
and
behavioral problems.
Speech-language
pathologists
can
play
an
important
role
in
providing
in-service
training
to
professionals
who
staff
these
settings.
With
the
passage
of
P.L.
99-457,
it
is
likely
that
speech-language
pathologists
will
have
increased
early
access
to
infants
and toddlers.
In
addition,
over
the
past
decade,
many
hospitals
across
the
nation
have
devel-
oped
follow-up
clinics in
developmental pediatric
set-
tings.
Follow-up
clinics
often
are
established
to
track
the
development
of
at-risk
children including
those
of
very
low
birthweight
or
those
who
may
experience perinatal
complications.
Hospital
follow-up clinics
often
refer
out
for
services
for
infants
and
toddlers, and
may
not
have
a
person
on
staff
who
can
provide regular
screening
or
speech-language
services.
Considering the
fact
that
pre-
mature
infants
and
infants
with
perinatal
complications
are
at
high
risk
for
the
development
of
communication
problems
and language-based
academic
problems
in
later
years (Rossetti,
1986),
the
role
of speech-language
pathol-
ogists
should continue
to
expand
in
these
settings
in
the
future.
Success
in
hospital settings
depends
on
develop-
ing
working
relationships
with
developmental pediatri-
cians,
developmental
psychologists,
occupational
thera-
pists,
and
other
professionals typically
employed
in
these
settings.
FURTHER
QUESTIONS
AND
RESEARCH
Many
questions
remain
about
the
interrelationships
between
communication
disorders
and emotional/behav-
ioral
disorders
in
children
and adolescents
and the
role
of
speech-language
pathologists
in
serving
this population.
These
questions
are
both
theoretical
and
practical
in
nature.
Theoretical
Questions
1.
What
is
the
natural
history
(i.e.,
progression) of
the
development
of emotional/behavioral
disorders
in chil-
dren
with
communication
disorders?
Although
there
is
little
empirical
evidence,
many
emo-
tional
and
behavioral disorders
directly
or
indirectly
may
be
a
consequence
of
a
child experiencing
a
communica-
tion disorder.
Questions
that
remain
center
around
the
specific
processes
that
are
operational.
For
example,
are
there
critical
periods
in
development
in which
children
with communication
disorders
experience
heightened
psychosocial stress
that
may
lead
to
the
development
of
emotional
and
behavioral disorders?
If
a
transactional
process
is
operational,
what
is
the nature
of caregivers'
behavior
that
may
lead
to,
or
preclude
the
development
of,
emotional/behavioral disorders.
Prospective
longitudi-
nal
research
is
needed
to
address such
questions.
2.
How does
a
communication
disorder
affect
a
child's
psychosocial
environment,
and
how
do
psychosocial
stressors
affect
communicative
growth?
Children
who
have
difficulty
communicating
no
doubt
have
a
significant
impact
on
their
psychosocial environ-
ment. In
a
transactional process,
parents
may
become
frustrated with
such
children,
may
communicate
or
inter-
act less
with
them,
or
may
provide
for
their
needs
to
an
excessive
degree.
As
noted,
there
has
been
specific
inter-
est
recently
in
the
degree
of
risk
for
neglect
or
physical
abuse
experienced
by
children
with
speech and
language
disorders (McCauley &
Swisher,
1987).
These
issues
need
to
be
addressed
in
future research. Conversely,
there
is
little
information
about
how
significant
psycho-
social
stress
may
affect
a
child's
communicative develop-
ment
or
be
a
factor
in
the
development
of
a
communica-
tion disorder. For
example,
so-called
electively
mute
children
may
be
responding
to
significant psychosocial
stress,
such
as
a
death
in
the
family
or
moving
to
a
new
home
(APA, 1987).
A
great
deal
more
information
is
needed
about
these
mutual influences.
3.
Can
specific
causal
relationships
between
specific
communication
disorders and emotional/behavioral
dis-
orders
be identified?
Baker
and Cantwell
(1987a)
have
raised
issues
of
these
relationships.
As
noted, they
found
that
a
higher
percent-
age
of children
with
language
disorders
alone,
rather
than
speech disorders
or
speech/language
disorders,
were
more
likely
to
experience
co-occurring
emotional
or
be-
havioral
disorders.
However,
more specific
relationships
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190
Journal
of
Speech
and
Hearing
Disorders
have
not
yet
been
identified. For
example,
do
early
disorders
of
language
processing
lead
to
mood
disorders
(e.g.,
depression)
resulting
in
a
child's
being
withdrawn?
Or,
are
mild
cognitive
deficits,
weaknesses,
or
disorgani-
zation-which
often
co-occur
with
language
disorders-
part
and
parcel of
an
emotional
disorder
or
behavioral
disorder
as
well?
Clearly,
these
issues
can
only be
an-
swered through
further
investigation.
4.
In
a
cumulative
risk
model,
which
risk
factors
are
most
predictive
of
emotional
and behavioral functioning
in
communicatively
disordered
children?
The
work
of
Baker
and
Cantwell
(1987a)
has
begun
to
identify
risk
factors
such
as
type of
communication
disor-
der,
presence
of
psychosocial
stressors,
sex,
and
non-
language
developmental
disorders
that
seem
to
be pre-
dictive of
later
emotional/behavioral
difficulties.
Further
work
is
needed
in
this
area
to
help delineate,
for
example,
the
specific
types
of
psychosocial
stressors
and
other
risk
factors
that
may
be
a
significant
determinant
of
emotional
and behavioral
outcome.
Practical
Issues
Many
questions
need
to
be
addressed
concerning the
provision
of
speech and
language
services
to
this popu-
lation
of
children
and
adolescents.
These
questions
in-
clude:
1. What
is
the
impact
of
speech
and
language
remedi-
ation on
emotional/behavioral functioning
of
children
with
communication disorders?
It
is
only
through
careful
monitoring of the
effects
of
speech
and
language
therapy
on
both
communication
functioning and
on
emotional
and
behavioral
functioning
that
this
relationship
can
be
determined.
Clinically,
this
information
can
be most
adequately obtained
by
working
closely
with
other
professionals
who
are
monitoring the
child's
emotional
and
behavioral
functioning.
Research
with
more
social
and
cognitively
impaired
populations,
such
as
individuals
with
autism,
has
demonstrated
that
acquisition
of
specific
communicative
means
to
express
the
function
of protest
or
escape results
in
reduction
of
aggression
or
socially
unacceptable
protesting
behaviors
(Carr
&
Durand,
1985;
Prizant
&
Wetherby,
1987).
These
relationships
need
to
be
considered
in
other
populations
of
individuals
with
communication
disorders.
2.
What
is
the
impact of
psychotherapy
on
communica-
tion
and behavioral
functioning
of
children
with
commu-
nication
disorders?
Psychotherapy
is
a
very
broad
category
of cognitive
and
behavioral
based
approaches
to
working
with
children
with emotional and behavioral problems.
Psychothera-
pies
may
include
verbally based therapies,
play
thera-
pies,
and
group
therapies
incorporating
psychodrama
and
peer
feedback.
In
general,
the
objectives
of psychother-
apy
include
helping
children
to
recognize
their
problem
and
to
develop
internalized
controls
and
strategies
to
deal
with
these
problems.
Intuitively,
it
would
seem
that
greater
awareness of emotional/behavioral
difficulties
and
the
development
of
internalized
controls
and
strategies
should lead
to
an
improvement
in communication.
The
specific
effects
of
various
psychotherapeutic
approaches
on
communication
functioning remains
an
open
question.
3.
How can
speech-language
pathologists
become
more
centrally involved
with this
population?
Certainly,
professionals in
speech
and
language
have
become
more
involved
over
the
past
few
years
in
serving
this population.
However,
our
experience
suggests
that
there
is a
great
deal
more
to
be done.
In
our clinical
setting,
we
find
that
mental
health
professionals
entering
our
facility
need
to
be in-serviced
on
a
regular
basis.
For
professionals
in
private practice,
contacting
community
mental
health
centers
or
settings
that
serve
children
and
adolescents
with emotional/behavioral problems
is
an-
other
strategy
to
become
more
involved.
What
must
be
recognized
is
that
professionals
in
speech-language
pa-
thology
must
assume
the responsibility
for
educating
mental
health
professionals
as
to
our
role
and relevance
for
this
population.
4.
What
types
of
preservice
and
practicum
training
should
be incorporated into graduate
programs
to
prepare
speech-language pathologists
to work
with
this
popula-
tion
in
all
settings?
Very
few
professionals in
speech-language
pathology
currently
have
the
expertise
to
incorporate
information
concerning
emotional
and behavioral disorders
into
course curricula.
As
this expertise
is
developing,
it
is
important
that university-based
professionals
utilize
staff
and
faculty
from
other university departments including
child
and
adolescent
psychiatry, psychology,
special
ed-
ucation,
and
social
work
who
can
provide
basic
informa-
tion
regarding
diagnosis
and
treatment of
children
with
emotional
and
behavioral
disorders.
Interdisciplinary
curricula,
such
as
those
between
special
education
and
speech-language
pathology,
provide
an
especially
fruitful
approach
to
exposing
graduate
students
in
speech-lan-
guage
pathology
to
this
information.
Certainly,
practicum
experiences
in
settings
serving
children
with
emotional
and
behavioral
disorders
should
be sought
out
and
place-
ments
arranged
if
future professionals
in
speech-language
pathology
are
to
take
their
rightful
place
in
working with
this
population.
5.
What are
the
best
modes
of service
delivery
for
providing
speech and
language
therapy
for
children
with
emotional
and behavioral
disorders?
Because
of
the
multiple
problems
experienced
by
these
children
and
adolescents, reliance primarily
on
a
"pull-
out"
model
may
be
inappropriate.
Many
of
these
children
and adolescents
may
not
experience
major
problems
in
one-to-one
interactions
with
adults.
They
may
experience
their
most
severe
problems
in
peer
interactions
or
in
environments
making great
demands
on
attention
and
self-control. Modes
of
service
delivery must
be
decided
based
upon
a
child's
communication and
learning
profile,
the environments
available, caseload
size,
supportive
personnel
and
so
forth
(Prizant,
1985).
At
the
very
least,
based
on
our
experience,
the
use
of
a
treatment
team
model
incorporating
regular
meetings
and mutual
deci-
sion
making
is
the
best
approach.
55
179-192
May
1990O
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PRIZANT
ET
AL.:
Emotional/Behavioral
Disorders
191
Additionally,
family
issues
and
concerns
should
be
major
factors
in
providing appropriate
services. When
possible,
family
members
should
be
an
integral
part of
the
treatment
team
and
help
the
team
to
set
priorities
concerning
specific
goals
and
objectives
to
be
targeted.
In
our
experience,
the
best
service
delivery
system
is
one
that
is
flexible to
individual
needs,
rigorous
in
addressing
concerns,
and
one
that
acknowledges
the
complex
inter-
relationships
between
behavioral/emotional
issues
and
communication issues.
SUMMARY
AND
CONCLUSIONS
Over the
past
two
decades,
professionals
who
deal with
children
and
adolescents
with
speech,
language,
and
communication
disorders
have progressed
from
focusing
on
speech
disorders and
affected
individuals
to
commu-
nication impairments
in
broader
situational
and
family
contexts.
This change
in
expertise
reflects
a
growing
sensitivity
to
the
complex
interrelationships
among
speech,
language,
and
communicative
competence,
and
emotional well-being.
Furthermore,
considerations
of
contexts
of
treatment
and
the
mutual
influence
between
communicatively
impaired persons
and
their
social
envi-
ronment
have
expanded
greatly.
It
is
highly
likely
that
as
research continues
to
document
the
high
prevalence
of
emotional/behavioral disorders
in
communicatively
im-
paired
children
and
adolescents,
as
well
as
the
high
proportion
of
communication disorders
in
children iden-
tified
as
having
emotional/behavioral
disorders,
profes-
sionals
in
speech-language
pathology
will
be
called upon
to
play a
greater and
more
complex
role
both
in
serving
these
individuals
as
well
as
in
interacting with mental
health
professionals.
It
is
our
contention
that
speech-
language pathologists
must
begin
to
prepare
to
meet
this
challenge.
ACKNOWLEDGMENTS
This
article
is
a
collaborative
effort
of
the
staff
of
the
Commu-
nication
Disorders
Department of
Emma
Pendleton
Bradley
Hospital,
one of
the
few
psychiatric centers
for
children
and
adolescents
in
the
United
States
with
a
fully
staffed
Communi-
cation
Disorders
Department,
and
the
home
base
of
the
Division
of
Child
and
Adolescent
Psychiatry
in
the
Brown
University
Program
in
Medicine.
The department
has
undergone
rapid
expansion
over
the
past
4
years
primarily
due
to
recognition
of
the pervasiveness of
communication disorders
in
children
and
adolescents
referred
for
emotional
and
behavioral
disorders.
With
the
challenges
faced
by
the
department
during
its devel-
opment,
the
staff
has become
increasingly
aware
of
the
limited
information
about
emotional
and
behavioral
problems
in
chil-
dren and
adolescents
provided
to
professionals
in
speech-lan-
guage
pathology
both
at
preservice
and
postgraduate levels.
The
information
presented
in
this
article is drawn
from
the
available
literature
and
from
the
experiences
of
the
staff
of
Bradley
Hospital's
Communication
Disorders
Department
in their
efforts
to
expand
services
to
patients
at
Bradley
Hospital,
to
educate
mental
health
professionals
about
communication
disorders
in
children
and adolescents, and
to
advocate
for
a
central
role
for
speech-language
pathologists
in
diagnosis
and
treatment
for
this
population.
The
authors
would
like to
thank
Marilyn
Newhoff
and
two
anonymous
reviewers
for
their
constructive
critique
of
an
earlier
form
of
this
paper.
We
are
grateful
to
Pat
Grifka
for
her
pains-
taking
preparation
and
revision
of
the manuscript
and
to our
colleagues at
Bradley
Hospital
for
insightful
discussions
about
issues
presented
in
this
paper.
Special
thanks
to
former
staff
member
Mary
Ann
Brayer
for
her
contributions.
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Accepted
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Requests
for
reprints
should
be
sent
to
Barry
M.
Prizant,
Ph.D.,
Communication
Disorders Department,
Emma
Pendle-
ton Bradley
Hospital,
1011
Veterans
Memorial
Parkway,
East
Providence,
RI 02915.
55
179-192
May
1990
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