Child Language Teaching and Therapy

26(2) 105–121
Young people with specific language © The Author(s) 2010
Reprints and permission: sagepub.
impairment: A review of social and co.uk/journalsPermissions.nav
DOI: 10.1177/0265659010368750
emotional functioning in adolescence http://clt.sagepub.com

Kevin Durkin
University of Strathclyde, Glasgow

Gina Conti-Ramsden
The University of Manchester, UK

Abstract
This article provides a review of research into the social and emotional functioning of adolescents
with specific language impairment (SLI). In particular, we focus on peer relations, peer friendships,
bullying, emotional difficulties and psychiatric difficulties. As a group, adolescents with SLI tend to
be more vulnerable to problems in these domains than are typical adolescents. However, there
is considerable heterogeneity among those with SLI, and some individuals experience positive
outcomes. We stress the need to understand adolescence and SLI in a developmental context.
The article concludes with a discussion of the implications of the research findings for service
provision to support the needs of young people with language impairments.

Keywords
language in adolescence, social development, social-emotional functioning interview, emotional
regulation, intervention

I  Introduction
Language and communication needs are identifiable in toddlers and, where problems or delays
become apparent, they tend to attract concern and treatment (Lindsay and Dockrell, 2004; Conti-
Ramsden et al., 2008). There are many reasons why a child may experience difficulties, but of
particular interest are children who have difficulties with language, i.e. with producing words to
communicate and/or understanding what is said to them, whilst ‘everything else’ appears to be
normal. That ‘everything else’ has traditionally been defined to include adequate input from the
senses: normal hearing and normal/corrected vision. It also includes an adequate biological basis
to develop language (the children have no obvious signs of brain damage) and an adequate basis

Corresponding author:
Kevin Durkin, Department of Psychology, University of Strathclyde, 40 George Street, Glasgow, G1 1QE, UK
Email: kevin.durkin@strath.ac.uk

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106 Child Language Teaching and Therapy 26(2)

for learning, i.e. their non-verbal abilities as measured by IQ are similar to those of their peers of
the same age. A desire to engage socially is also important: such children seek to interact socially
with adults and peers and as such are not like children with autism who are not as socially engaged.
These children are usually referred to as children with specific language impairment (SLI).
During adolescence the language problems of individuals with SLI are not always easily detect-
able in everyday conversation (Scott and Windsor, 2000; Nippold, 2007), and professional services
are less likely to be available for this age range (Dockrell et al., 2006). With the exception of severe
cases, many adolescents with SLI go unnoticed by the general public. Their language use may be
somewhat ‘shaky’ (Reed, 2005: 169) but the level of attainment of their oral language skills
appears, on the surface, to be adequate for everyday interactions.
Importantly, however, there are several fundamental reasons for attending to the special needs of
adolescents with SLI. First, these are young people with histories of being different. An individual’s
adolescence cannot be understood as wholly distinct from all that has happened during his or her
previous development, just as this crucial phase of life has in turn implications for his or her future
development (Durkin, 1995; Conti-Ramsden et al., 2008). In this review article, we use the term
‘adolescents with SLI’ for simplicity. However, we understand that this term encompasses a variety
of developmental histories. For example, children with SLI can include individuals with persistent
and resolved difficulties (Bishop and Edmundson, 1987). The term can also include those in adoles-
cence who may exhibit learning difficulties (Botting, 2005) or some autistic symptomatology (Conti-
Ramsden et al., 2006). Second, for many adolescents with SLI, language problems are still present,
and the fact that they are not always so readily apparent to others may exacerbate some of the difficul-
ties they occasion. Third, language difficulties tend to be associated, across development, with a
range of other behavioural, emotional and social difficulties, meaning that having SLI may signal the
possibility of other needs. Fourth, there are expanding demands on communicative skills during ado-
lescence, including some (such as peer relations) in spheres that are less accessible to therapists and
educators yet have wide-ranging implications for a young person’s adjustment and well-being.
By definition, young people with SLI are within the normal intelligence range, yet have lan-
guage impairments inconsistent with this (Leonard, 1998). Paradoxically, it is not usually oral
language but other areas of functioning that draw attention to adolescents with SLI in school set-
tings. These young people have associated difficulties with literacy (Dockrell and Lindsay, 1998;
Botting et al., 2006; Catts et al., 2008), and academic achievement (Snowling et al., 2001; Conti-
Ramsden et al., 2009). This comes as no surprise, as language ability is a well-recognized factor in
the development of literacy (St Clair et al., 2010), numeracy (Durkin and Shire, 1991; Donlan et al.,
2007) and other academic skills (Long, 2005; Dockrell et al., 2007). Other aspects of development
are also likely to be affected. Thus, there is a discrepancy between the young person’s broad intel-
lectual capacity and what he or she is able to realize in the classroom. Adolescents with SLI may
adjust to this by setting their sights lower. For example, Durkin et al. (2009b) found that, among
17-year-olds with the same level of relatively low mean examination scores, those with typical
development described themselves as ‘not satisfied’ with their educational achievements, while
those with SLI described themselves as ‘satisfied’. In other domains, it may be more difficult to
reconcile one’s status with one’s needs. For example, as we show below, the adolescent with SLI
may, like any other adolescent, desire to interact with others yet have compromised abilities to
participate in everyday discourse. These conflicts have the potential to cause tensions within the
individual, which may not always be noticed by others.
In this article, we review research into the social and emotional functioning of adolescents with
SLI. In particular, we focus on peer relations and friendships, bullying, emotional and psychiatric
difficulties. We conclude with a discussion of the implications of the research findings for service
provision to support the needs of these individuals.

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Durkin and Conti-Ramsden 107

II  Peer relations and friendship

Peers are a highly salient and motivating feature of the social landscape of most children (Durkin,
1995). From infancy, children pay particular attention to their age mates and enjoy time spent in
joint activities with them. Peers provide a context for social comparison, for exchange of informa-
tion and understanding, and for the rehearsal of practical and social skills. Within peer relations,
friendships are particularly important. Friendships are key markers of the selectivity of interper-
sonal relations, providing social and cognitive scaffolding (Hartup, 1996; Rubin et al., 2009), serv-
ing variously as sources of support and information as well as buffers against many of life’s
problems, with enduring implications for self-esteem and well-being (Hartup and Stevens, 1999).
Children and adolescents without friends, or with poor friendship quality, are at risk of loneliness
and stress (Ladd et al., 1996; Bagwell et al., 2005; Whitehouse et al., 2009a).
Since the early 1990s a body of research on peer relations in children with SLI has shown that,
from at least their preschool days, these children are at a disadvantage. They engage less in active
conversational interactions than do those with typical language, enter less frequently into positive
social interactions, are less sensitive to the initiations offered by others, have poorer discourse
skills, manifest situationally-inappropriate verbal responses, achieve fewer mutual decisions and
are more likely to have their bids to influence others prove unsuccessful (Hadley and Rice, 1991;
Craig, 1993; Craig and Washington, 1993; Grove et al., 1993; Guralnick et al., 1996; Brinton et al.,
1998; Vallance et al., 1999).
Language and communicative abilities are not the only factors that may impede peer relations.
Children with SLI tend also to score lower than typically developing children on a range of mea-
sures of social skills, social cognitive abilities and difficulties in emotional and behavioural self-
regulation (Fujiki et al., 1996; Cohen et al., 1998; Lindsay and Dockrell, 2000; Fujiki et al., 2002;
Marton et al., 2005; Lindsay et al., 2007). They tend to be rated as more withdrawn than age-
matched comparisons (Fujiki et al., 1996; Cohen et al., 1998; Redmond and Rice, 1998; Brinton
and Fujiki, 1999; Fujiki et al., 2001), yet they are at heightened risk of exhibiting externalizing
problems and antisocial conduct disorders (Beitchman et al., 2001; Brownlie et al., 2004; Conti-
Ramsden and Botting, 2004). They are less likely to exhibit skilled prosocial behaviour (Stevens
and Bliss, 1995; Fujiki et al., 1999). Brinton et al. (2000) suggest that language difficulties, social
withdrawal and a lack of prosocial skills are compounded, with the outcome that children find it
difficult to work in collaborative peer groups. Thus, deficits in other fundamental interpersonal
capacities appear to be associated with SLI in childhood.
What, then, of peer relations in adolescence? Peers are especially significant during this phase
of development. Time spent with the family declines, and time spent with peers increases
(Buhrmester, 1996). Reflecting developmental changes, young people strive to satisfy increasingly
complex needs via peer networks and friendships. Adolescents have psychological needs for inti-
macy, shared outlooks and identity formulation (Hartup and Stevens, 1999; Steinberg and Morris,
2001; Kroger, 2006). Experiencing difficulties with peer relations and friendships during child-
hood means that many young people with SLI enter adolescence less equipped and less practised
in the skills needed for this area of life, and quite likely less confident in their abilities.
Importantly, adolescents with SLI are motivated to socialize. In respect of new media use (e.g.
email, texting and instant messaging), for example, they attach as much value to interpersonal
communications as do typically developing age mates (Durkin et al., 2009a). Wadman et al. (2008)
found no difference between a sample of adolescents with SLI and a comparison group of typically
developing peers on the Cheek and Buss (1981) Sociability Scale, which measures preference for
being with others. Example items include: ‘I like to be with people,’ ‘I prefer working with others
rather than alone,’ and ‘I welcome the opportunity to mix socially with people.’ However, while the

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108 Child Language Teaching and Therapy 26(2)

adolescents with SLI were on a par with typically developing adolescents on this instrument, they
scored significantly lower than the typically developing group on a measure of self-esteem and
higher on a measure of shyness. Researchers observing children with SLI have reported that they
often appear to wish to approach others but to be fearful of doing so (Fujiki et al., 2004; Hart et al.,
2004). This ambivalence seems to persist into adolescence.
Furthermore, accumulating evidence confirms that other social and behavioural difficulties,
such as those noted above, are not short-term problems in individuals with SLI. A pattern of social
difficulties is characteristic not only of relatively early peer relations but remains marked through
later childhood and adolescence (Stevens and Bliss, 1995; Brinton et al., 1997; Fujiki et al., 1997;
Brinton et al., 1998; Conti-Ramsden and Botting, 2004; Durkin and Conti-Ramsden, 2007), and
into adulthood (Howlin et al., 2000; Clegg et al., 2005).
In one of our own studies (Durkin and Conti-Ramsden, 2007), we examined friendship quality
in a sample of adolescents with SLI and their typical language development peers whilst they were
attending secondary education, at age 16 years. Participants answered a series of questions regard-
ing friends and acquaintances from the social-emotional functioning interview (SEF-I; Howlin et al.,
2000). These questions included ‘How easy do you find it to get on with other people?’ and ‘If you
were at a party or social gathering, would you try to talk to people you had not met before?’
Possible scores ranged from 0 to 16, with scores closer to zero representing good quality of friend-
ships. The scores of adolescents with SLI ranged from 0 to 14, while adolescents with typical
language development scored between 0 and 2. Overall, as a group, adolescents with SLI were at
risk of poorer quality of friendships.
We then examined predictors of friendships and found that spoken language abilities (expres-
sion and understanding of language) as well as literacy skills (reading) were associated with
friendship quality. But language was not the strongest predictor; these were measures of difficult
behaviour and prosocial behaviour. In the sample as a whole, language and literacy measures
accounted for an additional 7% of variance. Thus, language ability is predictive of adolescents’
friendship quality when other behavioural characteristics known to be influential in peer relations
(problem behaviour, prosocial behaviour) are controlled for, but its overall influence is small.
There was also a small influence of non-verbal IQ. In order of importance, the variables predic-
tive of friendship quality were: difficult behaviour, prosocial behaviour, language and literacy,
and non-verbal IQ.
Between-group differences should not blind us to heterogeneity within groups. Although much
evidence points to difficulties with peer relations in individuals with SLI from childhood to adoles-
cence, it is nonetheless important to take note that there is a range of outcomes. Durkin and
Conti-Ramsden (2007) found that a large proportion of adolescents with SLI reported good quality
of friendships (60%), with 40% experiencing poor friendship quality. We examined the extent to
which early measures of language (at age 7 years) predicted the likelihood of obtaining a good or
poor friendship score at age 16 years. After adjusting for the effect of non-verbal IQ, receptive lan-
guage at 7 years of age was identified as a significant predictive factor for friendship outcome at 16
years of age. Difficulties with receptive language are virtually always accompanied by difficulties
with expressive language (Conti-Ramsden and Botting, 1999). In contrast, expressive difficulties
can occur in the context of adequate language comprehension skills. Thus, the mix of expressive and
receptive problems in some individuals is indicative of a more severe impairment and seems to be
predictive of poor friendship quality in adolescence. This relationship held after controlling for
measures of emotional and behavioural difficulties at 7 years of age. This outcome is consistent with
other research indicating that early language problems are predictive of persistent social difficulties
over the long term (Beitchman et al., 1996; Howlin et al., 2000). Strikingly in our study, for the poor

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Durkin and Conti-Ramsden 109

friendship group, poor language remained quite stable across a 9-year span, from 7 through to 16
years of age, particularly as indexed by receptive skills.
Why should language ability impact on friendships? Language serves many functions in social
interaction, and there is evidence that it is used in distinctive ways during friendship formation.
Friends spend more time talking to each other than do non-friends, and the nature of friends’ interac-
tions entails greater linguistic reciprocity (Hartup, 1996; Asher and Gazelle, 1999). Difficulties in
respect of language use put individuals at greater risk of poor friendship quality. One possibility
discussed in Durkin and Conti-Ramsden (2007) is that poor language skills that include poor recep-
tive ability are associated with poor theory of mind development, which in turn impacts on social
relationships. The ability to infer others’ perspectives and to appreciate possible differences in
knowledge or beliefs from one’s own may well bear on the development of skills in social selectivity
and on perceived congeniality. However, findings on theory of mind in individuals with SLI have
been mixed. Several studies have found that children with SLI perform as well as typically develop-
ing peers on theory of mind tasks (Leslie and Frith, 1988; Perner et al., 1989; Ziatas et al., 1998). On
the other hand, Clegg et al. (2005) reported that adult participants with SLI performed less well on
more subtle measures of theory of mind than both their non-impaired siblings and a comparison
group of IQ-matched adults without language difficulties. The nature of the relationship between
theory of mind and social adaptation in individuals with SLI remains in need of further investiga-
tion. Relatively little attention has been paid, for example, to the ways in which theory of mind may
intersect with emotional knowledge / emotion understanding. It may be that awareness of others’
feelings and reactions is more pertinent to friendship than is awareness of others’ cognitions per se,
and SLI may impact on this subtle dimension of interpersonal sensitivity.
Further research is needed also to determine whether there is anything distinctive about the
friendships that adolescents with SLI form. For example, some evidence from younger children
with special needs indicates that they are less likely to be favoured as friends by mainstream chil-
dren (Thompson et al., 1994). Hence, it is possible that adolescents with SLI are more likely to
form friendships with other adolescents with SLI, or perhaps adolescents with other learning dis-
abilities. This may be partly because they are more likely to spend time with these peers when
receiving support for special educational needs (Simkin and Conti-Ramsden, 2009), and partly
because they may share the consequences of being marginalized in their broader peer community.
Forming friendships with others with special needs is not necessarily problematic in itself.
However, the evidence reviewed above establishes that individuals with SLI are, on average, at
greater risk of manifesting problem behaviour, including aggression, and are less likely to display
prosocial behaviour. Hence, clusters of adolescents with these difficulties may have their individ-
ual problems compounded. Research with conduct-disordered and delinquent adolescents indi-
cates that association with deviant peers is prognostic of higher levels of adolescent problem
behaviour (Dishion et al., 2004; Carroll et al., 2009). Of course, we are not proposing that this is
an inevitable route for adolescents with SLI, many of whom will establish satisfactory peer rela-
tions and most of whom will not enter trajectories towards serious antisocial or delinquent behav-
iour. Nevertheless, there are disproportionate numbers of individuals with SLI among those in
serious trouble at school and in delinquent services (see below). Entry to antisocial peer groups is
a risk for some young people with SLI in some circumstances, and this underscores the need for
research into the needs of young people with SLI that goes beyond psycholinguistic and cognitive
concerns to encompass their social and emotional development.
From the above discussion, there are two key messages we would like to emphasize. On the one
hand, it is important to bear in mind that language problems are not a guarantee of social problems
(Brinton and Fujiki, 2002). Indeed, although social difficulties may distinguish individuals with

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110 Child Language Teaching and Therapy 26(2)

SLI from their typical peers, they are not usually in the clinical range (Redmond and Rice, 1998;
Botting and Conti-Ramsden, 2000; Wadman et al., 2008). Young people with SLI are heteroge-
neous in terms of their language characteristics, and this also holds true for their social abilities,
with some individuals achieving high levels of peer popularity (Fujiki et al., 1999; Brinton and
Fujiki, 2002). In the study by Durkin and Conti-Ramsden (2007) involving a large sample, a very
positive finding is that some 60% of adolescents with SLI reported good friendship quality. While
better language ability contributes part of the explanation of these favourable outcomes, it is clear
that other factors are involved and possible that strengths in one or more of these can mitigate any
effects due to impaired language. Prosocial behaviour, for example, can compensate for other char-
acteristics of individuals with SLI. Discomforts and breakdowns in communication may be toler-
ated by peers in the context of outward helpfulness and cooperativeness. These data discussed
above provide carers and professionals with the reassuring news that successful peer relations and
friendships are indeed possible for adolescents with SLI.
On the other hand, however, a significant proportion of adolescents with SLI have difficulties
in establishing and maintaining positive peer relations and friendships. These young people are
likely to exhibit more behavioural difficulties, less prosocial behaviours and poorer language skills
(Durkin and Conti-Ramsden, 2007). In the context of conduct difficulties and other manifest prob-
lems, relative impoverishment of friendship development may be less salient for carers, therapists
and teachers (Conti-Ramsden and Botting, 2004). There are also some indications that these ado-
lescents may have poorer emotional regulation (Fujiki et al., 2002) as well as lower self-esteem
(Jerome et al., 2002; Wadman et al., 2008). This constellation of needs of a proportion of adoles-
cents with SLI is likely to require multidisciplinary professional intervention and support through-
out secondary schooling and beyond.

III  Bullying
The term ‘bullying’ is used to describe the abuse of power with the intent to physically or emotion-
ally harm an individual (Rigby, 2002). The term bullying implies repetition: it has to happen more
than once. Bullying can take many forms, such as teasing and name-calling (verbal bullying), hit-
ting or pushing (physical bullying), intimidation through social exclusion or threats (emotional
bullying), and writing offensive messages via the use of new media (cyber-bullying).
Developmentally, verbal, physical and emotional bullying appears to decrease over time from
childhood through to adolescence. Nonetheless, the transition to secondary education appears to
present particular challenges to young people. A number of researchers have observed that the
incidence of bullying in educational settings appears to peak upon entry to secondary education
(Pellegrini and Long, 2002; Pepler et al., 2006).
Individuals with SLI, just as other groups of young people starting secondary education, are
thus at the highest risk of being bullied and victimized. However, the risk of being bullied is con-
siderably higher for individuals with a variety of special needs and disabilities. For example, indi-
viduals with learning disabilities appear to be at a greater risk of physical bullying (Mishna, 2003).
Individuals with conditions that affect their appearance such as Down syndrome, cleft palate or
cerebral palsy are more likely to suffer from verbal bullying (Dawkins, 1996; Nash et al., 2001). In
the case of individuals with language and communication difficulties perhaps the highest incidence
of bullying occurs in young people who stammer. Over 80% of adults who stammer report being
bullied in school (Hugh-Jones and Smith, 1999). For those young people with less obvious lan-
guage impairments, the small but growing research literature suggests that they are also at increased
risk of being bullied. Savage (2005) found that at secondary school entry (11 years of age), young

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people attending a speech and language resource attached to a mainstream school were 3 times
more likely to experience bullying than their mainstream peers. We had similar findings in our own
studies. Conti-Ramsden and Botting (2004) found that 36% of a sample of 11 year olds with SLI
reported being bullied. This figure was 12% for their typical language development age peers. This
was the case regardless of whether young people were attending mainstream education or special
educational contexts (Knox and Conti-Ramsden, 2003). Incidents involved physical, verbal and
emotional bullying such as being kicked or hit, being told they would be beaten up, or being threat-
ened for money.
In a recent study, Knox and Conti-Ramsden (2007) examined bullying developmentally whilst
young people were attending secondary education. These authors examined reports of current bul-
lying at age 16 years as well as earlier bullying experiences (retrospective report). As found in
other studies, the incidence of bullying decreased throughout adolescence. By age 16, young peo-
ple with SLI were still more likely to experience bullying but the percentage had decreased to 17%
(from earlier figures of over a third of individuals). In line with existing research, the decrease in
bullying experience was also apparent for young people with typical language development (Pepler
et al., 2006). However, we also found that 13% of young people with SLI had experienced bullying
that persisted throughout their secondary schooling. This percentage was considerably greater than
that of their age peers (2.4%). It is reasonable to assume that the negative impact of bullying (see
below) may be compounded in cases of long-term bullying.
What are the factors that make young people with SLI more likely to experience bullying?
Interestingly, level of language ability as measured by language and literacy assessments do not
appear to contribute significantly to the risk of being bullied (Knox and Conti-Ramsden, 2003).
Thus, it appears that other co-existing difficulties of young people with SLI contribute to the ele-
vated vulnerability of this group as a whole and not severity of language impairments per se. Smith
(2004) reviews correlates of victims of bullying in 205 studies and finds that poor friendship qual-
ity, low number of friends, and low peer acceptance/higher peer rejection are the strongest factors
associated with being bullied. This evidence – when considered in association with the research on
friendships and peer relations in young people with SLI reviewed in the section above – provides
strong evidence for the role of quality of friendships and peer relations in developing our under-
standing of who may be at a higher risk of being bullied among young people with SLI.
We would like to draw attention to the fact that sometimes young people who are bullied are also
bullies themselves, and individuals with special needs are no exception (Whitney et al., 1992;
Unnever and Cornell, 2003). Individuals who are bullied in school may in turn bully weaker or
younger students. These young people not only require support as victims, but also in changing their
aggressive behaviours towards others. To our knowledge there is no research addressing the engage-
ment in bullying behaviours by individuals with SLI. This is an area where future research could
provide information that would be relevant for the management and support of these young people.
Experiencing bullying is likely to have negative impacts. It is known that victims of bullying
suffer from emotional sequelae such as higher psychosomatic and psychosocial problems, i.e. not
sleeping well, bed-wetting, feeling sad, and experiencing headaches and stomach aches (Williams
et al., 1996; Fekkes et al., 2006). Victims also have an increased likelihood of depression (Hawker
and Boulton, 1996) as well as other psychiatric difficulties including elevated levels of anxiety
(Kaltiala-Heino et al., 2000; Roland, 2002; McCabe et al., 2003; Knox and Conti-Ramsden, 2007).
There are individual differences in terms of how well children cope with bullying, and one of the
effective strategies can be to seek social support (Boyle and Hunter, 2004). The poignant reality for
adolescents with SLI is, as discussed above, that they may have lower social skills, experience
higher levels of shyness and feel less comfortable in approaching others. The means of coping

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through seeking social support may therefore be less readily available to them. The area of psychi-
atric difficulties in individuals with SLI is reviewed more fully below. However, it is clear that
educators and professionals working with these young people not only need to be alert with regard
to the incidence of bullying (both as victims and potentially as bullies) but also with the associated
difficulties that bullying experiences may bring for these individuals.

IV  Emotional and psychiatric difficulties

There have been a handful of studies examining quality of life and psychiatric outcomes in young
people with SLI (Cantwell and Baker, 1987; Beitchman et al., 2001; Clegg et al., 2005; Ripley and
Yuill, 2005; Whitehouse et al., 2009b). Beitchman et al. followed up a group of young people with
SLI from 5 to 19 years of age and assessed them throughout this period for the presence of possible
psychiatric difficulties. Individuals with SLI were found to be at greater risk of having attention
deficit hyperactivity disorders or ADHD (Beitchman et al., 1996) and later had higher rates of anxi-
ety disorders (Beitchman et al., 2001), aggressive behaviour (Brownlie et al., 2004) and substance
abuse (Beitchman et al., 2001). Clegg et al. (2005) followed a cohort of children from 4 years of
age to mid adulthood and found greater risk of psychiatric impairment (compared to both peers and
siblings), particularly concerning depression, social anxiety and schizoform/personality disorders.
Whitehouse et al. (2009b) also found evidence of social and emotional difficulties during adult-
hood in their sample of individuals with a history of childhood language disorders. Working with
boys who had been permanently excluded from school, Ripley and Yuill (2005) found that expres-
sive language problems were associated with high levels of emotional symptoms. In a sample of
15 adolescent boys who were at risk of permanent exclusion, Clegg et al. (2009) found that two
thirds had language difficulties, although specific associations between types of language impair-
ment and types of emotional and behaviour problems were less clear than in Ripley and Yuill’s
sample. Other studies have examined language in populations referred primarily for psychiatric
difficulties. Cohen et al. (1998), for example, found a higher than expected rate of undiagnosed
language impairment (40%) in their clinical sample.
This area is complicated because measures of mental health and emotional well-being are them-
selves typically verbal and sometimes quite demanding of language skills (Zeman et al., 2007).
The implications for the study of young people with SLI call for careful attention. On the one hand,
there is a risk of a confound in assessment when participants have lower language abilities as this
could lead to an exaggerated estimate of differences between SLI groups and typical development
groups. On the other hand, when interview or story-telling techniques are exploited as part of a
diagnostic or research context, there is a risk of underestimating difficulties, because less verbal
individuals might be less proficient in disclosing emotional concerns and/or relating complex event
structures (Wetherell et al., 2007). A review of 10 years of research in the area found strong evi-
dence that language impairments were often not picked up by child and adolescent mental-health
teams or professionals working with psychiatric disorders (Toppelberg and Shapiro, 2000). At the
very least, there is a need for researcher/practitioner awareness of the language abilities of adoles-
cents whom they are assessing in clinical settings.
It needs to be noted, nonetheless, that SLI is heterogeneous in nature and present a variety of
profiles of impairment and severity (Conti-Ramsden, 2008). Snowling et al. (2006), for example,
did not find evidence of a higher risk of psychiatric disorders. Their sample included a significant
proportion of young people who had resolved their language impairments following a diagnosis
at 5 years of age. Interestingly, when examining those with resolved SLI separately from those
with persistent SLI, it was evident that those with resolved SLI had good psychiatric outcomes.

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In contrast, those with SLI beyond 5 years of age exhibited a higher risk of psychiatric morbidity
in adolescence. In particular, Snowling et al. found that more individuals with SLI experienced
problems with attention (e.g. attention deficit/hyperactive disorder) as well as psychosocial
adjustment (e.g. social phobia).
In the same vein, Conti-Ramsden and Botting (2008) found a clear increased risk for psychiatric
disorders such as anxiety and depression in adolescents with SLI even when concurrent levels of
language and cognitive abilities were controlled for. In addition, the proportion of adolescents
scoring above the clinical threshold in these areas was larger in the group with SLI when compared
to their typical language development age peers for both anxiety (12% vs. 2%) and depression
(39% vs. 14%). This finding replicates other studies that have shown raised prevalence of psychi-
atric difficulties in those with SLI (e.g. Clegg et al., 2005) or increased incidence of SLI in children
referred psychiatrically (e.g. Cohen et al., 1998) and reviews affirming the association (Toppelberg
and Shapiro, 2000). Beitchman et al. (2001) in particular found anxiety increased in a similar
cohort of young people with SLI at 19 years of age.
Conti-Ramsden and Botting (2008) also found that the typical gender difference protecting boys
from internalizing psychiatric disorders such as anxiety and depression was not evident in adoles-
cents with SLI. Thus, increased risk of anxiety and depression appears to affect males and females
relatively equally in those with SLI. This was not the case for participants with typical language
development. For these young people, the typical gender difference was observed whereby females
are more prone to internalizing psychiatric disorders than males in adolescence. Thus gender may
not be a predictive factor for individuals with SLI.
Another issue raised by the Conti-Ramsden and Botting (2008) study is that, apart from the fact
that those with SLI had increased internalizing psychiatric symptoms in the form of anxiety and
depression, surprisingly few clear associations existed with language abilities. Their results sug-
gest that there were virtually no associations between level of language ability and the develop-
ment of anxiety and depression in adolescence. Examination of early factors suggested that those
with emotional problems at 7 years of age also show increased anxiety at 16 years of age. Earlier
language, though, showed remarkably few associations. Thus, level of language was not a predic-
tor of anxiety and depression in adolescents with SLI. This is similar to the findings of Clegg et al.
(2005), who also failed to find a clear relationship between the two. Literacy difficulties were also
unrelated, ruling out academic attainment as a potential direct cause.
The lack of association with early language scores also makes it more difficult to interpret the
relationship between having poor language and internalizing psychiatric difficulties as a directly
developmentally causal one. Having ongoing poor communicative experiences does not appear to
‘make you’ increasingly depressed or anxious per se. Cohen et al. (2000) examined groups with
language impairments, psychiatric disorder or both and showed that specific cognitive difficulties
such as executive function, memory abilities and visual-motor integration were most marked in the
last of these groups. Although Conti-Ramsden and Botting (2008) found no association between
general non-verbal IQ (early and concurrent) and internalizing psychiatric disorders, specific cog-
nitive difficulties have been linked with both language impairment (Ellis-Weismer et al., 1999) and
with depression (Fossati et al., 1999). More sensitive measures of cognitive skills may have
revealed a connection in these studies.
In addition, there are at least two important factors to consider: support available and self-help.
First, the level of social support individuals with SLI may receive at home and at school is likely
to be influential. From the review in the first section of this article, we know that some individuals
with SLI have poor friendships and peer relations and thus may lack a key element of support in
their lives. Less is known about the types of support young people with SLI have at home during

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114 Child Language Teaching and Therapy 26(2)

adolescence. What we do know is that although parents may find raising an individual with SLI
rewarding this process can oftentimes be demanding and stressful (Glidden and Schoolcraft, 2007;
Conti-Ramsden et al., 2008). There is also a body of literature showing that having a child with SLI
predicts higher rates of anxiety and depression in parents (Veisson, 1999; Ollson and Hwang,
2001). We also know that social deprivation and poverty lead to poor conditions including hunger,
overcrowding, and unsafe neighbourhoods and schools. These factors are likely to impact on the
well-being of individuals and their ability to provide support for children and adolescents with SLI.
Furthermore, the lack of resources associated with low socio-economic status is itself a risk factor
for individuals developing both language problems and emotional/behavioural difficulties
(Roseberry-McKibbin, 2007). By no means all young people with SLI grow up at economic disad-
vantage, but those who do may be at compounded risk.
Second, how young people see themselves and whether they have been able to compensate
for their language and related difficulties in some ways may be important. For example, adoles-
cents may develop a policy of ‘letting others do the talking’ while still actively seeking to partici-
pate in social activities/interactions (versus opting for withdrawal). In addition, the types of
experiences they have had may also influence adolescents’ vulnerability to anxiety and/or
depression. From the data reviewed in Section II of this article, we know that negative experi-
ences – for example, whether or not an individual has been bullied in school – are likely to play
a role (Knox and Conti-Ramsden, 2007). What is clear is that social and emotional functioning
are interwoven with other developmental and environmental processes in adolescence and that
together these contribute to the complex and heterogeneous outcomes of young people with SLI.
What is also clear is the need for support for these individuals. The data reviewed in this article
echo the work of Maughan (1995) with young people with reading difficulties. Like Maughan,
we suggest that guidance and support at important transition points in the lives of young people
may be amongst the most important contributions that carers and professionals can make to these
individuals during adolescence.

V  Implications for service provision

At present, there appears to be no cohesive, integrated approach to service provision for individu-
als with SLI during adolescence (Nash et al., 2001; Dockrell et al., 2006). Much of what is avail-
able focuses on preschool and early school-age children and there are fewer services available and
fewer professionals working at secondary school level (Reed, 2005; Dockrell et al., 2006).
‘Prevention’ is a key buzzword, and the aim is to avoid or at least ameliorate the likely academic,
social and emotional sequelae of SLI. In a recent UK government report (Bercow, 2008) there was
clear emphasis on the need for a continuum of services and joint working across professional
groups and agencies (including schools and health services) in planning and delivering support for
children and young people with SLI. Although the report gives priority to early identification and
intervention, there was a welcome recognition that older children and adolescents also require sup-
port, that they deserve a continuum of services, and that this is likely to require joint working
across professional groups and organizations.
The evidence reviewed above emphasizes the need to raise awareness and develop the breadth
and depth of service provision for adolescents with SLI. In this respect there is much work yet to
be done. From the point of view of the speech and language therapy profession there is a dearth of
information with regard to both assessment tools and intervention frameworks for SLI during ado-
lescence. There are a limited number of standardized and criterion-referenced assessment tools for
language, let alone for other areas of functioning (e.g. social and emotional functioning) which

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Durkin and Conti-Ramsden 115

take into consideration the potential difficulties that young people with SLI may present during
assessment. There is also a paucity of information about what intervention strategies are appropri-
ate for different types of difficulties at this later stage of development. Altogether, it may be fair to
say that speech and language therapists feel ill-equipped to tackle the needs of adolescents with
SLI in secondary education.
There are signs of progress, nonetheless. In a recent initiative, the Nuffield Foundation has
funded research specifically aimed at developing intervention strategies for adolescents with SLI
(Victoria Joffe, principal investigator; The Nuffield Foundation, 2006). In addition, in 2009, the
Royal College of Speech and Language Therapists supported the development of a national special
interest group on older children and young adults with developmental speech, language and com-
munication needs. This group is open to a variety of individuals with an interest in older children
and young people, including speech and language therapists, teaching assistants, support staff,
teachers, youth workers, mental-health workers, academics, young people with language and com-
munication difficulties themselves, and the young people’s parents and families. This initiative has
built joint working across professional groups as well as key stakeholders right from the start. It
also has the potential to be an important vehicle for liaising across organizations, as well as raising
awareness of the needs of individuals with SLI. From the work reviewed above, for example, it
follows that speech and language therapists should be working in close collaboration with counsel-
ling, community medicine, educational psychologists and child and adolescent mental-health
teams. Professionals in the field report that this still does not happen enough in practice, although
this is particularly important when we are working with adolescents due to the complexity of dif-
ficulties these individuals are likely to present with. Ideally, speech and language therapists should
be part of the relevant teams. In particular, we are aware of the need for closer working relation-
ships between child and adolescent mental-health teams and speech and language therapists. As
mentioned earlier, there is a need to raise awareness amongst professionals of the possible associa-
tions of SLI with social, emotional and psychiatric difficulties. As part of the team, speech and
language therapists can facilitate this process. Speech and language therapists can inform relevant
professionals how to manage and support individuals with SLI, i.e. in the assessment of their
developmental history (which should include language abilities), the assessment of their social,
emotional and psychiatric difficulties and – very importantly – in considering the efficacy of any
verbally mediated therapy they may use as part of their intervention strategies. This closer collab-
orative approach could also have benefits for speech and language therapists. Speech and language
therapists may gain a more holistic view of the young person’s abilities and the factors beyond dif-
ficulties with language that may be affecting his or her well-being.
We have stressed here that the period of adolescence of people with SLI needs to be viewed in
a developmental context: we should not overlook the implications of their experiences as children,
nor the demands that will be placed on them as adults. Adolescence is a period of change, with
consequences for how the young person thinks of himself or herself, and how he or she relates to
others and to the broader society. During this crucial life transition, individuals with SLI are likely
to be in need of support in a variety of areas of functioning. Speech and language therapists face
many challenges in meeting these needs and in coordinating with educators and other profession-
als. Importantly, they have the opportunity to be key advocates for these young people who are not
always in a position to be able to speak for themselves.

Acknowledgements
The authors gratefully acknowledge the support of the Nuffield Foundation (grants AT 251 [OD], DIR/28 and
EDU 8366) and the Wellcome Trust (grant 060774); they also acknowledge the support of the Economic and

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116 Child Language Teaching and Therapy 26(2)

Social Research Council (ESRC) for a fellowship to Gina Conti-Ramsden (RES-063-27-0066). We would
also like to thank the young people and their families who have taken part in our studies over many years.

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