Is this Language Disorder developmental or acquired?

by Lisa Archibald

DLD Diagnostics Flowcharts

Scenario: A school-age child is referred to SLP/SALT services. The SLP/SALT assessment indicates the presence of a persistent language disorder with a significant impact on everyday interactions or school learning and no associated biomedical condition. The final question for the diagnostic decision in this scenario is to decide if the language disorder is developmental (making the diagnosis of DLD warranted) or acquired (making the diagnosis a Language Disorder associated with the injury). 

Developmental Language Disorder (DLD) refers to a persistent language difficulty with a significant impact on everyday interactions or school learning that is not associated with a relevant biomedical condition. The term ‘Developmental’ in DLD means that the condition starts over the course of development. DLD is not acquired after birth and it is not associated with a known biomedical cause. A disorder that is not developmental is an acquired condition. A language disorder arising from an acquired injury such as a traumatic brain injury (TBI) would be described as a Language Disorder associated with TBI (or other relevant injury).

When confirming the developmental nature of a childhood condition, SLP/SALTs look for evidence of developmental concerns arising early in the child’s life. All too often, in the case of DLD, however, such evidence is not available. Volume 7 of the #DLDToolbox considers when the diagnosis of DLD is warranted even without clear evidence of early developmental concerns.

In this scenario, we already know that the diagnostic criteria for DLD have been met: There are (1) persistent (#DLDToolbox v. 5) (2) language difficulties (3) with a significant impact on everyday interactions or school learning, and (4) the language disorder is not associated with a known differentiating biomedical condition (#DLDToolbox v. 2, 4, 6). The only question remaining concerns the developmental nature of the condition. Volume 7 addresses 3 possible outcomes to this scenario.

(1) Developmental concerns are confirmed

Caregivers provide a history of developmental concerns regarding the child’s language development. In the volume 7 scenario, this evidence then confirms the diagnosis of DLD. 

(2) Acquired injuries are confirmed

Caregivers provide a history of an acquired injury in the child’s development that would be reasonably expected to impact language development. In this case, the diagnosis of Language Disorder associated with the injury would be given.

(3) There is no available evidence of developmental concerns or acquired injuries

In the case when there is no evidence available to definitively ‘rule in’ the developmental or acquired nature of the condition, it is reasonable to assume that the condition is developmental and to provide the diagnosis of DLD. There are two reasons why this assumption is warranted: (1) developmental signs of language difficulties are often undetected and (2) developmental conditions are much more common than acquired conditions.

Developmental signs of language difficulties are often undetected

The lack of available evidence of developmental concerns when assessing DLD is relatively common. We know that DLD is frequently undetected until School entry (Calder et al., 2022; Tomblin et al., 1997). It may be that this under identification was because no one in the child’s community was concerned about the child’s development. The lack of these concerns, however, is not definitive evidence against developmental signs of DLD. DLD is a hidden disorder and language development is variable. Caregivers in the child’s environment may not detect the child’s language struggles (even though they may exist).

We also know that family history and other early indicators of developmental concern are not strong predictors of DLD (Calder et al., 2024). The absence of any risk factors does not rule out developmental concerns regarding DLD.

Developmental conditions are much more common than acquired conditions

When definitive evidence in unavailable regarding the developmental or acquired nature of a child’s language disorder, the SLP/SALT can consider which condition is the more likely. In fact, developmental conditions are much more common. In developed countries, the prevalence of parent-reported traumatic brain injuries in children 4 years or younger range from 0.6% (Haarbauer-Krupa et al., 2018) to 3.3% (Wang et al., 2023). The incidence of pediatric stroke is 1.2 to 13 cases per 100,000 children under 18 (Rawanduzy et al., 2022). Even amongst children with a lifetime history of traumatic brain injury, speech and/or language problems occur in about 18.6% of cases (Haarbeurer-Krupa et al., 2018). These figures indicate that acquired conditions are rare in children and may not always be associated with a language disorder. A lack of evidence for an acquired condition impacting language development can rule out this explanation with reasonable confidence. 

Notably, the prevalence of DLD at 7.2% (Norbury et al., 2016) makes this developmental condition much more common than the possibility of an acquired condition. When there is no history of an acquired condition, the assumption that a school age child’s language disorder is developmental is warranted even without a definitive history of developmental concerns.

A final note is to recognize that developmental and acquired conditions are not mutually exclusive. That is, a child with a developmental condition could acquire another condition during their lifetime. A child with DLD could sustain an injury that impacted their language development or language skills and so acquire additional language difficulties due to the injury.

 

Calder et al. (2022). The prevalence of and potential risk factors for Developmental Language Disorder. Journal of Pediatrics and Child Health, 58, 2044-50.

Calder et al. (2024). Do parent-reported early indicators predict later developmental language disorder? A Raine Study investigation. International Journal of Language and Communication Disorders, 59:396-412. 

Haarbauer-Krupa et al. (2018). Prevalence of parent-reported traumatic brain injury in children and associated health conditions. JAMA Pediatrics, 172:1078-86.

Norbury et al. (2016). The impact of nonverbal ability on prevalence and clinical presentation of language disorder: evidence from a population study. Journal of Child Psychology and Psychiatry, 57:1247-57.

Rawanduzy et al. (2022) Pediatric stroke: a review of common etiologies and management strategies. Biomedicines, 11:2, doi: . 

Tomblin et al. (1997). Prevalence of specific language disorder in kindergarten children. Journal of Speech, Language, and Hearing Research, 40:1245-60.

Wang et al. (2023, February). Injuries among Canadian children and youth: an analysis using the 2019 Canadian Health Survey on Children and Youth. Health Promotion & Chronic Disease Prevention in Canada: RPP, 43(2), doi: 10.24095/hpcdp.43.2.05.