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Communication Disorders and Emotional/Behavioral Disorders in Children and

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 Journal of Speech and Hearing Disorders,Volume 55, 179-192, May 1990

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

THEORETICAL ISSUES The nature of this relationship has been discussed in

The Relationship Between Communication
Disorders and PsychiatricDisorders
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)
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 179 0022-4677/90/5502-0179$01.00/0

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 180 Journal of Speech and HearingDisorders
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 PsychiatricDisorders
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 Diagnosticand 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
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55 179-192 May 1990
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
dangerof 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

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.
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PRIZANT ET AL.: EmotionallBehavioralDisorders 181
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-ThirdEdition
(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 (1988a) 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
 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 PsychiatricDisorders in
Communicatively DisorderedChildren 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-
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55 179-192 May 1990
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
Psychiatricdisorder impaired(n = 135) (n = 137)
Emotionally disturbed 12.8 1.5
Attention deficit disorder 30.4 4.5
Conduct disorder 5.5 6.0

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
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PRIZANT ET AL.: EmotionallBehavioralDisorders 183
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-
 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.
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55 179-192 May 1990
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-

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-
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PRIZANT ET AL.: Emotional/BehavioralDisorders 185
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.
 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
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55 179-192 May 1990
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

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
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PRIZANT ET AL.: EmotionallBehavioralDisorders 187
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
 188 Journal of Speech and HearingDisorders
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
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55 179-192 May 1990
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

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.
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PRIZANT ET AL.: EmotionallBehavioralDisorders 189
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
 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.
PracticalIssues
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
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55 179-192 May 1990O
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.

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.
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PRIZANT ET AL.: Emotional/BehavioralDisorders 191
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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Received July 18. 1988
Accepted April 26, 1989
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.