CHILD LANGUAGE DISORDERS

Unit 2: Characteristics of Developmental and Acquired Child

Language Disorders

2.1 Linguistic, Prosodic, Behavioral and Literacy

Characteristics in Children with Intellectual Disability

Submitted by: Vidhyashivani.G

Faculty: Dr. Priya MB
INTELLECTUAL DISABILITY
Description: ICD-11, Disorders of intellectual development

Disorders of intellectual development are a group of etiologically diverse conditions originating

during the developmental period characterized by significantly below average intellectual functioning
and adaptive behavior that are approximately two or more standard deviations below the mean based
on appropriately normed, individually administered standardized tests.

Diagnostic criteria:
The presence of significant limitations in intellectual functioning across various domains such as
perceptual reasoning, working memory, processing speed, and verbal comprehension.
The presence of significant limitations in adaptive behaviour, which refers to the set of conceptual,
social, and practical skills that have been learned and are performed by people in their everyday
lives. Conceptual skills are those that involve the application of knowledge (e.g., reading, writing,
calculating, solving problems, and making decisions) and communication; social skills include
managing interpersonal interactions and relationships, social responsibility, following rules and
obeying laws, as well as avoiding victimization; and practical skills are involved in areas such as self-
care, health and safety, occupational skills, recreation, use of money, mobility and transportation, as
well as use of home appliances and technological devices. Expectations of adaptive functioning may
change in response to environmental demands that change with age.

Onset occurs during the developmental period. Among adults with Disorders of Intellectual
Development who come to clinical attention without a previous diagnosis, it is possible to establish
developmental onset through the person’s history, i.e., retrospective diagnosis.

DSM 5:
Intellectual disability (intellectual developmental disorder) is a disorder with onset during the
developmental period that includes both intellectual and adaptive functioning deficits in conceptual,
social, and practical domains.
The following three criteria must be met:
A. Deficits in intellectual functions, such as reasoning, problem solving, planning, abstract thinking,
judgment, academic learning, and learning from experience, confirmed by both clinical assessment
and individualized, standardized intelligence testing.
B. Deficits in adaptive functioning that result in failure to meet developmental and sociocultural
standards for personal independence and social responsibility. Without ongoing support, the adaptive
deficits limit functioning in one or more activities of daily life, such as communication, social
participation, and independent living, across multiple environments, such as home, school, work, and
community.

C. Onset of intellectual and adaptive deficits during the developmental period.

Severity:
ICD-11:

Mild Disorder of Intellectual Development

● In Mild Disorder of Intellectual Development, intellectual functioning and adaptive behaviour

are found to be approximately 2 to 3 standard deviations below the mean (approximately 0.1
– 2.3 percentile), based on appropriately normed, individually administered standardized
tests. Where standardized tests are not available, assessment of intellectual functioning and
adaptive behaviour requires greater reliance on clinical judgment, which may include the use
of behavioural indicators provided in Tables 6.1 through 6.4. Persons with a Mild Disorder of
Intellectual Development often exhibit difficulties in the acquisition and comprehension of
complex language concepts and academic skills. Most master basic self-care, domestic, and
practical activities. Affected persons can generally achieve relatively independent living and
employment as adults but may require appropriate support.

Moderate Disorder of Intellectual Development

● In Moderate Disorder of Intellectual Development, intellectual functioning and adaptive

behaviour are found to be approximately 3 to 4 standard deviations below the mean
(approximately 0.003 – 0.1 percentile), based on appropriately normed, individually
administered standardized tests. Where standardized tests are not available, assessment of
intellectual functioning and adaptive behaviour requires greater reliance on clinical judgment,
which may include the use of behavioural indicators provided in Tables 6.1 through 6.4.
Language and capacity for acquisition of academic skills of persons affected by a Moderate
Disorder of Intellectual Development vary but are generally limited to basic skills. Some may
master basic self-care, domestic, and practical activities. Most affected persons require
considerable and consistent support in order to achieve independent living and employment as
adults.

Severe Disorder of Intellectual Development

● In Severe Disorder of Intellectual Development, intellectual functioning and adaptive

behaviour are found to be approximately 4 or more standard deviations below the mean (less
than approximately the 0.003rd percentile), based on appropriately normed, individually
administered standardized tests. Where standardized tests are not available, assessment of
intellectual functioning and adaptive behaviour requires greater reliance on clinical judgment,
which may include the use of behavioural indicators provided in Tables 6.1 through 6.4.
Persons affected by a Severe Disorder of Intellectual Development exhibit very limited
language and capacity for acquisition of academic skills. They may also have motor
impairments and typically require daily support in a supervised environment for adequate
care, but may acquire basic self-care skills with intensive training. Severe and Profound
Disorders of Intellectual Development are differentiated exclusively on the basis of adaptive
behaviour differences because existing standardized tests of intelligence cannot reliably or
validly distinguish among individuals with intellectual functioning below the 0.003rd
percentile.
Profound Disorder of Intellectual Development

● In Profound Disorder of Intellectual Development, intellectual functioning and adaptive

behaviour are found to be approximately 4 or more standard deviations below the mean
(approximately less than the 0.003rd percentile), based on individually administered
appropriately normed, standardized tests. Where standardized tests are not available,
assessment of intellectual functioning and adaptive behaviour requires greater reliance on
clinical judgment, which may include the use of behavioural indicators provided in Tables 6.1
through 6.4. Persons affected by a Profound Disorder of Intellectual Development possess
very limited communication abilities and capacity for acquisition of academic skills is
restricted to basic concrete skills. They may also have co-occurring motor and sensory
impairments and typically require daily support in a supervised environment for adequate
care. Severe and Profound Disorders of Intellectual Development are differentiated
exclusively on the basis of adaptive behaviour differences because existing standardized tests
of intelligence cannot reliably or validly distinguish among individuals with intellectual
functioning below the 0.003rd percentile.

Severity specifiers:
The severity of a Disorder of Intellectual Development is determined by considering both the
individual’s level of intellectual ability and level of adaptive behaviour, ideally assessed using
appropriately normed, individually administered standardized tests.
Generally, the level of severity should be assigned on the basis of the level at which the majority of
the individual’s intellectual ability and adaptive behaviour skills across all three domains (i.e.,
conceptual, social, and practical skills) fall.

TABLE 6.1: BEHAVIOURAL INDICATORS OF INTELLECTUAL FUNCTIONING

Childhood &
Early Childhood
Adolescence Adulthood
(Determination of
(Determination of (Determination of severity
severity should be
SEVERITY severity should be should be reassessed after
reassessed after
LEVEL reassessed after appropriate educational
appropriate educational
appropriate educational services and supports are
services and supports
services and supports are provided)
are provided)
provided)

MILD By the end of this During this - Most can communicate

developmental period: developmental period, fluently.
- Most will develop there is evidence of the - Many can tell or identify
language skills and be emergence of or their birth date.
able to communicate presence of the - Most can initiate/invite
needs. Delays in the abilities listed below. others to participate in an
acquisition of - Most can activity.
language skills are communicate - Most can communicate
typical and once effectively. about past, present, and
 Childhood &
Early Childhood
Adolescence Adulthood
(Determination of
(Determination of (Determination of severity
severity should be
SEVERITY severity should be should be reassessed after
reassessed after
LEVEL reassessed after appropriate educational
appropriate educational
appropriate educational services and supports are
services and supports
services and supports are provided)
are provided)
provided)
acquired are - Most can tell or future events.
frequently less identify their age. - Most can attend to and
developed than - Most can follow up to 3-step
typically-developing initiate/invite others to instructions.
peers (e.g., more participate in an - Most can identify
limited vocabulary). activity. different denominations of
- Most can tell or - Most can money (e.g., coins) and
identify their gender communicate about count money more or less
and age. past, present and future accurately.
- Most can attend to a events. - Most can orient
simple cause-effect - Most can attend to themselves in the
relationship. and follow up to 3-step community and learn to
- Most can attend to instructions. travel to new places using
and follow up to 2- - Most can identify different modes of
step instructions. different transportation with
- Most can make one- denominations of instruction / training.
to-one money (e.g., coins) - Some can learn the road
correspondence or and count small laws and meet
match to sample (e.g., amounts of money. requirements to obtain a
organize or match - Most can cross street driver’s license. Travel is
items according to intersections safely mainly restricted to
shape, size, colour). (look in both familiar environments.
- Most can directions, wait for - Most can cross residential
communicate their traffic to clear before street intersections safely
immediate future crossing, obey traffic (look in both directions,
goals (e.g., desired signals). In contexts wait for traffic to clear
activities for the day) without busy before crossing, obey
- Most can express intersections, most can traffic signals). In contexts
their likes and dislikes follow socially without busy intersections,
in relationships (e.g., acceptable rules most can follow socially
who they prefer to necessary to ensure acceptable rules necessary
spend time with), personal safety. to ensure personal safety.
activities, food, and - Most can Most can communicate
dress. communicate their their decisions about their
future goals and future goals, health care,
Literacy / Numeracy participate in their and relationships (e.g.,
health care. who they prefer to spend
- Most will develop - Most can identify time with).
emergent reading and many of their relatives - Most can apply existing
writing skills. and their relationships. abilities in the context of
- Most will be able to - Most can apply semi-skilled employment
recognize letters from existing abilities in (i.e., involving the
their name and some order to build skills for performance of routine
can recognize their future semi-skilled operations) and in some
 Childhood &
Early Childhood
Adolescence Adulthood
(Determination of
(Determination of (Determination of severity
severity should be
SEVERITY severity should be should be reassessed after
reassessed after
LEVEL reassessed after appropriate educational
appropriate educational
appropriate educational services and supports are
services and supports
services and supports are provided)
are provided)
provided)
own name in print. employment (i.e., cases skilled employment
involving the (e.g., requiring some
performance of routine independent judgment and
operations) and in responsibility).
some cases skilled - Most remain naive in
employment (e.g., anticipating full
requiring some consequences of actions or
independent judgment recognizing when someone
and responsibility). is trying to exploit them.
- Most are naive in - Most have difficulty in
anticipating full handling complex
consequences of situations such as
actions or recognizing managing bank accounts
when someone is and long-term money
trying to exploit them. management.
- Some can orient
themselves in the Literacy / Numeracy
community and travel
to new places using - Most can read and write
familiar modes of up to approximately a level
transportation. expected for someone who
has attended 7 to 8 years of
Literacy / Numeracy schooling (i.e., start of
middle school), and read
- Most can read simple material for
sentences with five information and
common words. entertainment.
- Most can count and - Most can count,
make simple additions understand mathematical
and subtractions. concepts, and make simple
mathematical calculations.

MODERATE - Most will develop - Most can - Most can communicate

language skills and be communicate their with reasonable fluency in
able to communicate needs effectively. short sentences.
needs. Delays in the - Most can tell or - Most can tell or identify
acquisition of identify their age and their age.
language skills are gender. - Most can initiate/invite
typical and once - Most can others to participate in an
acquired are often less initiate/invite others to activity.
developed than participate in an - Most can communicate
typically-developing activity. immediate experiences.
peers (e.g., more - Most can - Most can attend to and
 Childhood &
Early Childhood
Adolescence Adulthood
(Determination of
(Determination of (Determination of severity
severity should be
SEVERITY severity should be should be reassessed after
reassessed after
LEVEL reassessed after appropriate educational
appropriate educational
appropriate educational services and supports are
services and supports
services and supports are provided)
are provided)
provided)
limited vocabulary). communicate follow up to 2-step
- Most can follow immediate instructions.
one-step directions. experiences. - Most can cross residential
- Most can self- - Most can attend to street intersections safely
initiate activities and and follow up to 2-step (look in both directions,
participate in parallel instructions. wait for traffic to clear
play. Some develop - Some can cross before crossing, obey
simple interactive residential street lights and signal signals).
play. intersections safely In contexts without busy
- Some can attend to a (look in both intersections, some can
simple cause-effect directions, waiting for follow socially acceptable
relationship. traffic to clear before rules necessary to ensure
- Most can distinguish crossing, obey lights personal safety.
between “more” and and signal signals). In - Some can travel
“less.” contexts without busy independently to familiar
- Some can make one- intersections, some can places.
to-one follow socially - Most can communicate
correspondence or acceptable rules their preferences about
match to sample (e.g., necessary to ensure their future goals, health
organize or match personal safety. care, and relationships
items according to - Some can go (e.g., who they prefer to
shape, size, colour). independently to spend time with) and will
- Many can express nearby familiar places. often act in accordance
their likes and dislikes - Most can with these preferences.
in relationships (e.g., communicate - Some can apply existing
who they prefer to preferences about their abilities in the context of
spend time with), future goals when semi-skilled employment
activities, food, and provided with options. (i.e., involving the
dress. - Most can express performance of routine
their likes and dislikes operations).
Literacy / Numeracy in relationships (e.g., - Most remain naive in
who they prefer to anticipating full
- Most can recognize spend time with), consequences of actions or
symbols. activities, food, and recognizing when someone
dress. is trying to exploit them.
- With support, most
can apply existing Literacy / Numeracy
abilities in order to
build skills for future - Most can read sentences
semi-skilled with three common words
employment (i.e., and can achieve a reading
involving the and writing level up to that
performance of routine expected of someone who
operations) has attended 4 to 5 years of
 Childhood &
Early Childhood
Adolescence Adulthood
(Determination of
(Determination of (Determination of severity
severity should be
SEVERITY severity should be should be reassessed after
reassessed after
LEVEL reassessed after appropriate educational
appropriate educational
appropriate educational services and supports are
services and supports
services and supports are provided)
are provided)
provided)
- Most are naive in schooling (i.e., several
anticipating full years of
consequences of primary/elementary
actions or recognizing school).
when someone is - Most can choose correct
trying to exploit them. number of objects.
- Most can count to 10 and
Literacy / Numeracy in some cases higher.

- Most will develop

emergent reading and
writing skills.
- Most can recognize
their own name in
print.
- Most can choose
correct number of
objects.
- Some can learn to
count up to 10.

SEVERE - Most will develop - Most can use - Most can use
various simple non- communication communication strategies
verbal strategies to strategies to indicate to indicate preferences.
communicate basic preferences. - Most can self-initiate
needs. - Most can self-initiate activities.
- Some can self- activities. - Most can attend to and
initiate activities. - Most can attend to recognize familiar pictures.
- Most can attend to and recognize familiar - Most can follow 1-step
and respond to others. pictures.Most can instructions and stop an
- Most can separate follow 1-step activity upon request.
one object from a instructions and stop - Most can distinguish
group upon request. an activity upon between “more” and
- Most can stop an request. “less.”
activity upon request. - Most can distinguish - Most can separate one
- Most can express between “more” and object from a group upon
their likes and dislikes “less.” request.
in relationships (e.g., - Most can separate - Most can differentiate
who they prefer to one object from a locations and associated
spend time with), group upon request. meanings (car, kitchen,
activities, food, and - Most can bathroom, school, doctor’s
dress when given differentiate locations office, etc.)
concrete choices (e.g., and associate - Most can communicate
 Childhood &
Early Childhood
Adolescence Adulthood
(Determination of
(Determination of (Determination of severity
severity should be
SEVERITY severity should be should be reassessed after
reassessed after
LEVEL reassessed after appropriate educational
appropriate educational
appropriate educational services and supports are
services and supports
services and supports are provided)
are provided)
provided)
with visual aids). meanings (car, kitchen, their preferences about
bathroom, school, their future goals, health
Literacy / Numeracy doctor’s office, etc.) care, and relationships
- Most can express (e.g., who they prefer to
- Most can make their likes and dislikes spend time with) when
rudimentary marks in relationships (e.g., given concrete choices
that are pre-cursors to who they prefer to (e.g., with visual aids).
letters on page. spend time with), - Some can apply existing
activities, food, and skills to obtain unskilled
dress when given employment (i.e.,
concrete choices (e.g., involving performing
with visual aids). simple duties) or semi-
- With support, some skilled employment (i.e.,
may be able to apply involving performing
existing abilities in routine operations) with
order to build skills for appropriate social and
future unskilled visual/verbal supports.
employment (i.e.,
involving performing Literacy / Numeracy
simple duties) or semi-
skilled employment - Most can recognize
(i.e., involving common pictures (e.g.,
performing routine house, ball, flower).
operations). - Many can recognize
letters from an alphabet.
Literacy / Numeracy

- Most can recognize

symbols.
- Many can recognize
own name in print.

PROFOUND
- Many will develop - Most will develop - Most will develop non-
non-verbal strategies strategies to verbal strategies and some
to communicate basic communicate basic utterances /occasional
needs. needs and preferences. words to communicate
- Most can attend to - Most can recognize basic needs and
and respond to others. familiar people in preferences.
- Most can start or person and in - Most can attend to and
stop activities with photographs. recognize familiar pictures.
prompts and aids. - Most can perform - Most can perform very
- Many can express very simple tasks with simple tasks with prompts
 Childhood &
Early Childhood
Adolescence Adulthood
(Determination of
(Determination of (Determination of severity
severity should be
SEVERITY severity should be should be reassessed after
reassessed after
LEVEL reassessed after appropriate educational
appropriate educational
appropriate educational services and supports are
services and supports
services and supports are provided)
are provided)
provided)
their likes and dislikes prompts and aids. and aids.
in relationships (e.g., - Some can separate - Some can separate one
who they prefer to one object from a object from a group upon
spend time with), group upon request. request.
activities, food, and - Some can - Some can differentiate
dress when given differentiate locations locations and associated
concrete choices (e.g., and associated meanings (car, kitchen,
with visual aids). meanings (car, kitchen, bathroom, school, doctor’s
bathroom, school, office, etc.)
Literacy / Numeracy doctor’s office, etc.) - Many can communicate
- Many can express their preferences about
- They will not learn their likes and dislikes their future goals, health
to read or write. in relationships (e.g., care, and relationships
who they prefer to (e.g., who they prefer to
spend time with), spend time with) when
activities, food, and given concrete choices
dress when given (e.g., with visual aids).
concrete choices (e.g.,
with visual aids).

TABLE 6.2: BEHAVIOURAL INDICATORS OF ADAPTIVE BEHAVIOUR

EARLY CHILDHOOD (up to 6 years of age)

SEVERITY
Conceptual Social Practical
LEVEL

Reasoning, planning, Interpersonal competency Self-care,

organizing, reading, (e.g., relationships), social recreation,
writing, memory, judgment, emotion employment
symbolic/internal regulation. (including domestic
representation, chores), health and
communication skills. safety,
transportation.

MILD - Most can perform - Most can perform - Most will learn the
basic listening skills independently basic skills majority of basic
with a 15- minute related to social interaction eating, washing face
attention span. Most such as imitation, showing and hands, toileting,
need help to sustain affection to familiar and self-care skills.
SEVERITY
Conceptual Social Practical
LEVEL
their attention for 30 persons as well as friend-
minutes. seeking behaviour, - Most will acquire
expressing emotions, and independence in
- Most are able to answering basic questions. dressing (may need
follow simple 2-step help to button/fasten
instructions. They need - Most will need frequent clothes) and
help following a 3-step encouragement and nighttime
or “if-then” type of assistance in offering help continence.
instruction. to others, sharing interests,
or perspective taking. They - Most can use
- Most can state their are able to engage in play simple household
age and name and with others, even with devices.
identify close family minimal supervision
members when asked. although they will need - Most will need
assistance taking turns, supports with
- Many have a 100- following rules, or sharing. bathing, using
word vocabulary. Most utensils, toileting
ask “wh” question - Most are able to such as cleaning
(who, what, where, demonstrate polite after passing stools,
why) but most will need behaviour (saying “please”, and brushing teeth.
help using pronouns and “thank you”) although they
tense verbs. may need help apologizing, - Most can learn the
demonstrating appropriate concept of danger
- Most are not able to behaviour with strangers, and avoid hot
give a detailed account or waiting for the objects.
of their experiences. appropriate moment to
speak in a social context. - Most will be able
- Most will understand to independently
the simple concepts of - Most will need help to help with simple
time, space, distance modify their behaviour in household chores,
and spatial accordance to changing but will often need
relationships. social situations or when assistance with more
there is a change in their complex tasks such
Literacy routines. as putting away
clothes or cleaning
- Many will not learn up their rooms.
reading/writing skills. If
present, reading skills - With some
will be limited to assistance, most can
identifying some letters learn the concept of
of the alphabet. Only money (although
some will be able to will be unable to
recognize their own learn the value of the
name in print. different
denominations, e.g.,
coins), can count to
10, and follow basic
rules around the
home.
SEVERITY
Conceptual Social Practical
LEVEL
- Will be unable to
learn days of the
week, learn and
remember phone
numbers.

MODERATE - Most will - Most are able to perform - Most can learn the
independently point to independently some of the majority of basic
common objects when basic skills related to social eating skills, may
asked and follow 1-step interaction, although they need more assistance
instructions. Some will might need some help than their same-age
need supports to making new friends, peers with toilet
perform basic skills answering basic social training and dressing
such as following questions, or expressing themselves (some
simple 2-step their emotions. help needed to
instructions. button/fasten).
- Most are able to play with
- Most can state their peers and show interest in - Most will learn to
own name. play/interact with others, ask to use the toilet,
but may need more drink from a cup,
- Most will have basic supervision/supports to feed themselves with
communication skills play cooperatively with a spoon, and some
such as: formulating others, play symbolically, may become toilet
one-word requests, take turns, follow rules of a trained during
using simple phrases, game and share objects. daytime. Will often
using other people’s need supports with
customary ways of - Most will not be able to brushing teeth,
addressing (mommy, perform more complex bathing, and using
papa, sister) but will social skills involving utensils.
need help with full inter-personal interactions
names. such as offering help to - With some
others, empathy, sharing supports, most can
- Most speak at least 50 their interests with others learn to use simple
words and name/point at or perspective taking. household devices
least 10 objects when and carry out simple
asked. chores such as
putting away their
- Most are not able (or footwear.
will need considerable
support) to use past - Most can learn the
tense verbs, pronouns or concept of danger
“wh” questions. although some
assistance will be
Literacy needed when using
sharp objects (e.g.,
- Most will not learn scissors).
reading or writing skills,
but know how to use - Many will be able
pens and pencils and to help with very
SEVERITY
Conceptual Social Practical
LEVEL
make marks on a page. simple household
chores such as
cleaning fruits and
vegetables.

- Most will not

acquire the
understanding of the
concept of money
and time.

SEVERE - Most can perform - Most will need help to - Most can learn
independently the most perform basic social skills many of the basic
basic skills such as such as imitation or eating skills but will
wave good-bye, identify showing interest and need substantially
parent/caregiver, point preferences in social more assistance than
to a desired object and interactions with their their same-age peers
point or gesture to peers. with toilet training,
indicate their learning to use a cup
preference, and - Most are able to show and spoon, and
understanding the interest when someone else putting on clothes.
meaning of yes and no. is playful and to play
simple games. - Most can learn to
- Most will need use simple
supports to point - Most will need significant household devices
to/identify common supports to play in a with consistent
objects, follow 1-step cooperative way, play supports.
instructions, and sustain symbolically or seek others
their attention to listen for play/leisure activities. - Most will have
to a story for at least 5 difficulty learning to
minutes. - Most will need significant master many self-
help with transitions - care skills, including
- Most will not be able changing from one activity using the toilet
to state their age to another or an independently.
correctly and will speak unexpected change in
less than 50 routine. - Most will not be
recognizable words. able to learn the
They may need help - Most will need significant concept of danger
formulating 1-word help using polite social and will require
requests and using first responses such as “please” close supervision in
names or nicknames of and “thank you”. areas such as the
familiar people, naming kitchen.
objects, answering when - Most will not be able to
called upon, and using engage in turn-taking, - Some may learn
simple phrases. following rules or sharing basic cleaning skills
objects. such as washing
Literacy - Most may be able to hands but will
perform only the most consistently need
- Most will not learn basic social skills such as assistance.
 SEVERITY
Conceptual Social Practical
LEVEL
reading and writing smiling, orienting their
skills. gaze, looking at - Most will not learn
- Most will master only others/objects, or showing the concept of
the most basic basic emotions. money, time, or
communication skills numbers.
such as turning their eye - Some might be able to - Most will need
gaze and head towards a perform other basic social help performing
sound. skills with considerable even the most basic
support/prompting, such as eating, dressing,
- They will need showing preference for drinking, and
prompting to orient people or objects, imitating bathing skills.
towards people in their simple movements and
environment, respond expressions, or engaging in - Most will be
when their name is reciprocal social unable to learn to be
called, and understand interactions. independent using
the meaning of yes and the toilet, being dry
no. - Some can show interest during the day,
when someone else is bathing or washing
- They are able to cry playful, but will need self at the sink,
when hungry or wet, considerable support to using a fork and
smile and make sounds play simple games. knife.
of pleasure, but it may
be difficult to get their - Will have difficulty - Most will need
attention. adapting to changes and constant supervision
transitions in around potentially
Literacy activity/location. dangerous situations
in the home and
- They will not learn to - Most will be unable to community.
read or write. follow rules of a social
game. - Most will be
unable to clean up
after themselves;
will need help with
even basic chores,
such as picking up
belongings to put
away.

- Most will not be

able to learn to
independently use
the telephone or
other simple devices
around the home.

TABLE 6.4: BEHAVIOURAL INDICATORS OF ADAPTIVE BEHAVIOUR

ADULTHOOD (18+ year of age)
SEVERITY
Conceptual Social Practical
LEVEL

Reasoning, planning, Interpersonal competency Self-care,

organizing, reading, (e.g., relationships), social recreation,
writing, memory, judgment, emotion employment
symbolic/internal regulation (including domestic
representation, chores), health and
communication skills safety,
transportation

MILD - Most will master - Most can independently - Most will be

listening and meet others for the purpose
communication skills, of making new friends, can
although some may participate in social outings
need help to stay on on a regular basis, and talk
topic in group about personal feelings.
conversations, move
from one topic to - Most can independently
another, express ideas initiate a conversation and
in more than one way talk about shared interests
or states complete home with others.
address.
- Most can understand
- Most will probably social cues and are able to
not be able to give regulate their conversation
complex directions and based on their interpretation
describe long-term of other people’s feelings.
goals.
- Most are able to play
Literacy complex social games and
team sports, although may
- Most can read and need supports with
understand material up understanding the rules.
to that expected of
someone who has - Most can learn to weigh
attended 3 or 4 years of the possible consequences
primary/elementary of their actions before
school and will master making a decision in
some writing skills, familiar situations but not in
although they may have new or complex situations,
difficulty writing and know right from wrong.
reports and long essays.
- Most need help
recognizing when a
situation or relationship
might pose dangers or
someone might be
manipulating them for their
own gain.
independent in
household chores,
being safe around
the home, and using
the telephone and
TV; some will learn
operating the gas or
electric stove.
- Most will often
continue to need
some supports to
attain independence
with more complex
domestic skills (e.g.,
small household
repairs),
comparative
shopping for
consumer products,
following a healthy
diet and being
engaged in health
promoting
behaviours, caring
for themselves when
sick or knowing
what to do when
they are sick/ill.
- Many can learn to
live and work
independently, work
at a part-time or
full-time job with
competitive wages –
support at work will
depend on the level
of complexity of the
SEVERITY
Conceptual Social
LEVEL
- Most can initiate planning
of a social activity with
others. Some can be
engaged in an intimate
relationship, whereas others
might need more supports
to do so.
MODERATE - Most will need - Some will need help
considerable support to learning how to share
be able to attend to interests or engaging in
various tasks for more perspective taking.
than a 15-minute period
as well as following - Some may need supports
instructions or initiating conversations and
directions from memory introducing themselves to
(i.e., with a 5–minute unfamiliar people.
delay).
- Most need significant
- Most will master the supports engaging in
following regular social activities,
communication skills: planning social activities
simple descriptions, with others, understanding
using “wh” questions social cues, and knowing
(e.g., what, when, why, what are
where, etc.) or relating appropriate/inappropriate
their experiences using conversation topics.
simple sentences.
- Most will need significant
Practical
work and may
fluctuate with life
transitions.
- Some can learn to
drive a motor
vehicle or a bicycle,
manage simple
aspects of a bank
account, prepare
simple meals, and if
available, use a
computer or other
digital devices.
Many will learn to
use public transport
with minimal help.
- Most will continue
to need supports
with more complex
banking needs,
paying bills, driving
in busy roads, and
parenting skills.
- Some will learn to
master dressing
(may need some
help selecting
appropriate clothing
to wear for
weather), washing,
eating and toileting
needs.
- Most are able to be
safe around the
home, use the
telephone, use the
basic features of a
TV and use simple
appliances /
household articles
(e.g., switches,
stoves, microwave).
SEVERITY
Conceptual Social Practical
LEVEL
- With help, most are supports engaging in social - Some may
able to follow 3-step activities requiring continue to need
instructions. transportation. supports with
bathing and
- Most will continue - Most are unable to be showering, using
frequently needing help engaged in more social or more complex
with using language other games with complex household
containing past tenses rules (e.g., board games). appliances (e.g.,
and describing their stove) safely, meal
experiences in detail. - Most will need help preparation, or
providing socially polite using cleaning
- Most will not learn responses such as “please”, products safely.
more complex “thank you”.
conversation skills - Many will
(e.g., expressing ideas - Most are unable to understand the
in more than one way). recognize when a social function of money
situation might pose some but struggle with
Literacy danger to them (e.g., making change,
potential for abuse or budgeting and
- Most will acquire exploitation). making purchases
some reading and without being told
writing skills such as: what to buy.
letters of the alphabet,
writing at least three - Most will need
simple words from an supports being safe
example, and writing in the community
their own first and last and living
name. They will need independently. They
significant supports to will need substantial
write simple sentences supports for
or read simple stories at employment –
about that expected of finding and keeping
someone who has a job.
attended 2 years of
primary/elementary - Most will not
school. likely be able to
travel independently
to new places, have
a developed concept
of time sufficient to
tell time
independently and
know when they are
late.

SEVERE - Will often need life- - All will need help in social - Most will need
long supports to recall situations, showing and some supports for
and comply with expressing their emotions in even basic personal
instructions given 5 an appropriate manner, and hygiene, domestic
SEVERITY
Conceptual Social
LEVEL
minutes prior, sustain engaging in a reciprocal
their attention to a story conversation with others.
for a 15-minute period. - Most can play simple
Most are able to listen social games such as
and attend to a story for catching and throwing a
a period of at least 5 ball, but may need help
minutes. choosing friends to play
with. They need
- Most can make sounds considerable help to play
or gestures to get the symbolically, follow the
attention of individuals rules while playing games
in their environment such as turn-taking or
and can make their sharing toys.
needs known. - Most will need help with
transition - changing from
- They may need help one activity to the next or
using simple phrases, an unexpected change in
describing objects and routine.
relating their - Most will not
experiences to others, spontaneously use polite
speaks at least 100 forms such as “please”,
recognizable words, “excuse me”, “thank you”,
using negatives, etc. or respectful /
possessives and customary ways of
pronouns, and asking addressing others. They will
“wh” questions. need significant support
starting, maintaining and
Literacy ending conversations with
others.
- Reading and writing - Most do not recognize
skills will be limited to: when a social situation
identifying some letters might pose a danger to them
of the alphabet, copying (e.g., potential for abuse or
simple words from an exploitation) or discern
example and attempt to dangers potentially
write their name. associated with strangers.
Practical
skills, home and
community skills.
- Most will be able
to drink
independently from
a cup and learn to
use basic utensils
for eating. Some
may continue to
need supports
getting dressed.
- Many may learn
independent
toileting if provided
an established
routine. Most will
be unable to care for
their own
belongings, perform
household chores
independently,
cooking, or care for
their health.
- Most will need
substantial supports
to travel
independently, plan
and do shopping
and banking of any
sort.
- Most will require
significant supports
to be engaged in
paid employment.

PROFOUND - Most are able to turn - Most will not - Most will need
their head and eye gaze spontaneously show interest supports performing
toward sounds in their in peers or unfamiliar even the most basic
environment and individuals. self-care, eating,
respond to their name washing, and
when called. - With significant supports, domestic skills.
most are able to imitate
- Most will use sounds simple actions/behaviors or - Some may learn
and gestures to get show concern for others. independent
parent/caregiver’s toileting during the
SEVERITY
Conceptual Social Practical
LEVEL
attention, express their - Most will not engage in day but nighttime
wants, and some will reciprocal/back-and-forth continence will be
have the understanding conversation. more difficult.
of the meaning of yes
and no. Some are able - Most will not - Most will have
with prompting to wave spontaneously use polite difficulty picking
good-bye, use their forms such as “please”, out appropriate
parent’s/caregiver’s “excuse me”, “thank you”, clothing and zipping
name /customary ways etc. and snapping
of addressing others, clothes.
and point to objects to - Most are unable to
express their anticipate changes in - Most will need
preferences. routines. Social interactions supervision and
with others will be very supports for
- Most will cry or make basic and limited to bathing, including
vocalizations when essential wants and needs. safely adjusting
hungry or wet, smile, water temperature
and make sounds of - Most are unable to and washing/drying.
pleasure. recognize when a social
situation might pose some - Most will be
- Most are not able to danger to them (e.g., unable to
follow instructions or potential for abuse or independently clean
story being told. exploitation). or care for their
living environment,
- Most will have only including clothing
rudimentary knowledge and meal
of moving around preparation.
within their house.
- All will need
Literacy substantial supports
with health matters,
- Most will not learn to being safe in the
read or write. home and
community,
learning the concept
of days of the week
and time of day.

- Most will be
extremely limited in
their vocational
skills and
engagement in
employment
activities will
necessitate structure
and supports.
DSM-5:
The DSM-5 severity code indicates the severity of adaptive functioning across the three domains
(conceptual, social and practical skills).

Severity level Conceptual domain Social domain Practical domain

Mild For preschool Compared with The individual may

children, there may be typically developing function age-
no obvious conceptual age-mates, the appropriately in
differences. For individual is immature personal care.
school-age children in social interactions. Individuals need some
and adults, there are For example, there support with complex
difficulties in learning may be difficulty in daily living tasks in
academic skills accurately perceiving comparison to peers.
involving reading, peers’ social cues. In adulthood, supports
writing, arithmetic, Communication, typically involve
time, or money, with conversation, and grocery shopping,
support needed in one language are more transportation, home
or more areas to meet concrete or immature and child-care
age-related than expected for age. organizing, nutritious
expectations. In There may be food preparation, and
adults, abstract difficulties regulating banking and money
thinking, executive emotion and behavior management.
function (i.e., in age-appropriate Recreational skills
planning, strategizing, fashion; these resemble those of
priority setting, and difficulties are noticed agemates, although
cognitive flexibility), by peers in social judgment related to
and short-term situations. There is well-being and
memory, as well as limited understanding organization around
functional use of of risk in social recreation requires
academic skills (e.g., situations; social support. In adulthood,
reading, money judgment is immature competitive
management), are for age, and the person employment is often
impaired. There is a is at risk of being seen in jobs that do
somewhat concrete manipulated by others not emphasize
approach to problems (gullibility). conceptual skills.
and solutions Individuals generally
compared with age- need support to make
mates. health care decisions
and legal decisions,
and to learn to
perform a skilled
vocation competently.
Support is typically
needed to raise a
 family.

Moderate All through The individual shows The individual can

development, the marked differences care for personal
individual’s from peers in social needs involving
conceptual skills lag and communicative eating, dressing,
markedly behind those behavior across elimination, and
of peers. For pre- development. Spoken hygiene as an adult,
schoolers, language language is typically a although an extended
and preacademic skills primary tool for social period of teaching and
develop slowly. For communication but is time is needed for the
school-age children, much less complex individual to become
progress in reading, than that of peers. independent in these
writing, mathematics, Capacity for areas, and reminders
and understanding of relationships is may be needed.
time and money evident in ties to Similarly,
occurs slowly across family and friends, participation in all
the school years and is and the individual may household tasks can be
markedly limited have successful achieved by
compared with that of friendships across life adulthood, although an
peers. For adults, and sometimes extended period of
academic skill romantic relations in teaching is needed,
development is adulthood. However, and ongoing supports
typically at an individuals may not will typically occur for
elementary level, and perceive or interpret adult-level
support is required for social cues accurately. performance.
all use of academic Social judgment and Independent
skills in work and decision-making employment in jobs
personal life. Ongoing abilities are limited, that require limited
assistance on a daily and caretakers must conceptual and
basis is needed to assist the person with communication skills
complete conceptual life decisions. can be achieved, but
tasks of day-to-day Friendships with considerable support
life, and others may typically developing from co-workers,
take over these peers are often supervisors, and others
responsibilities fully affected by is needed to manage
for the individual. communication or social expectations,
social limitations. job complexities, and
Significant social and ancillary
communicative responsibilities such
support is needed in as scheduling,
work settings for transportation, health
success. benefits, and money
management. A
variety of recreational
skills can be
developed. These
typically require
 additional supports
and learning
opportunities over an
extended period of
time. Maladaptive
behavior is present in
a significant minority
and causes social
problems.

Severe Attainment of Spoken language is The individual

conceptual skills is quite limited in terms requires support for all
limited. The individual of vocabulary and activities of daily
generally has little grammar. Speech may living, including
understanding of be single words or meals, dressing,
written language or of phrases and may be bathing, and
concepts involving supplemented through elimination. The
numbers, quantity, augmentative means. individual requires
time, and money. Speech and supervision at all
Caretakers provide communication are times. The individual
extensive supports for focused on the here cannot make
problem solving and now within responsible decisions
throughout life. everyday events. regarding wellbeing of
Language is used for self or others. In
social communication adulthood,
more than for participation in tasks
explication. at home, recreation,
Individuals understand and work requires
simple speech and ongoing support and
gestural assistance. Skill
communication. acquisition in all
Relationships with domains involves
family members and long-term teaching
familiar others are a and ongoing support.
source of pleasure and Maladaptive behavior,
help including self-injury,
is present in a
significant minority

Profound Conceptual skills The individual has The individual is

generally involve the very limited dependent on others
physical world rather understanding of for all aspects of daily
than symbolic symbolic physical care, health,
processes. The communication in and safety, although
individual may use speech or gesture. He he or she may be able
objects in goal- or she may understand to participate in some
directed fashion for some simple of these activities as
self-care, work, and instructions or well. Individuals
 recreation. Certain gestures. The without severe
visuospatial skills, individual expresses physical impairments
such as matching and his or her own desires may assist with some
sorting based on and emotions largely daily work tasks at
physical through nonverbal, home, like carrying
characteristics, may be non-symbolic dishes to the table.
acquired. However, communication. The Simple actions with
co-occurring motor individual enjoys objects may be the
and sensory relationships with basis of participation
impairments may well-known family in some vocational
prevent functional use members, caretakers, activities with high
of objects. and familiar others, levels of ongoing
and initiates and support. Recreational
responds to social activities may involve,
interactions through for example,
gestural and emotional enjoyment in listening
cues. Co-occurring to music, watching
sensory and physical movies, going out for
impairments may walks, or participating
prevent many social in water activities, all
activities with the support of
others. Cooccurring
physical and sensory
impairments are
frequent barriers to
participation (beyond
watching) in home,
recreational, and
vocational activities.
Maladaptive behavior
is present in a
significant minority.

Additional clinical features (ICD-11):

There is no single physical feature or personality type common to all individuals with Disorders of
Intellectual Development, although specific aetiological groups may have common physical
characteristics.
Disorders of Intellectual Development are associated with a high rate of co-occurring Mental,
Behavioural or Neurodevelopmental Disorders. However, clinical presentations may vary depending
on the individual’s age, level of severity of the Disorder of Intellectual Development, communication
skills, and symptom complexity. Some disorders, such as Autism Spectrum Disorder, Depressive
Disorders, Bipolar or Related Disorders, Schizophrenia, Dementia, and Attention Deficit
Hyperactivity Disorder, occur more commonly than in the general population. Individuals with a co-
occurring Disorder of Intellectual Development and other Mental, Behavioural, or
Neurodevelopmental Disorders are at similar risk for suicide as individuals with mental disorders who
do not have a co-occurring Disorder of Intellectual Development.
Problem or challenging behaviours such as aggression, self-injurious behaviour, attention-seeking
behaviour, oppositional defiant behaviour, and sexually inappropriate behaviour are more frequent
among those with Disorders of Intellectual Development than in the general population.
Many individuals with Disorders of Intellectual Development are more gullible and naïve, easier to
deceive, and more prone to acquiescence and confabulation than people in the general population.
This can lead to various consequences including greater likelihood of victimization, becoming
involved in criminal activities, and providing inaccurate statements to law enforcement.
Significant life changes and traumatic experiences can be particularly difficult for a person with
Disorders of Intellectual Development. Whereas the timing and type of life transitions vary across
societies, it is generally the case that individuals with Disorders of Intellectual Development need
additional support adapting to changes in routine, structure, or educational or living arrangements.
There are many medical conditions that can cause Disorders of Intellectual Development and that are,
in turn, associated with specific additional medical problems. A variety of prenatal (e.g., exposure to
toxic substances or harmful medications), perinatal (e.g., labour and delivery problems), and postnatal
(e.g., infectious encephalopathies) factors may contribute to the development of Disorders of
Intellectual Development, and multiple aetiologies may interact. Early diagnosis of the aetiology of a
Disorder of Intellectual Development, when possible, can assist in the prevention and management of
related medical problems (e.g., frequent thyroid disease screening is recommended for individuals
with Down Syndrome). If the aetiology of a Disorder of Intellectual Development in a particular
individual has been established, the diagnosis corresponding to that aetiology should also be assigned.
Individuals with Disorders of Intellectual Development are at greater risk for a variety of health (e.g.,
epilepsy) and social (e.g., poverty) problems across the lifespan.

DSM VS ICD:
● Terminology:
DSM –V - Intellectual disability (Intellectual developmental disorder)
ICD – 11- Neurodevelopmental disorders – Disorders of Intellectual development.
Intellectual disability is the most widely used name in clinical and academic settings.
● DSM-5 defines intellectual functions more elaborately as reasoning, problem-solving,
planning, abstract thinking, judgment, academic learning, and learning from instruction and
experience, and practical understanding confirmed by both clinical assessment and
standardized tests.
● ICD-11 gives much significance to appropriately normed, standardized tests for intellectual
function, and adaptive behavioral assessment. It also provides clinical behavior indicators in
cases where normed and standardized tests are inaccessible.
● Both ICD-11 and DSM-5 have not specified an upper age limit for the developmental period.
(Practical difficulty –in case of decline in intellectual function due to acquired conditions like
trauma after the age of 19 or 22 years)
● Both ICD -11 and DSM-V categorizes ID into 4 major severity levels. But, ICD -11 warrants
standardized assessments of both intellectual and adaptive functioning, whereas DSM-V
 specifies the severity levels on the basis of adaptive functioning, and not IQ scores, because
it is adaptive functioning that determines the level of supports required.
● DSM –V: includes the nomenclature of GDD for children below age 5 years, who are too
young to participate in standard developmental assessment tests for intellectual and
adaptive functioning but show evidence of delay in attainment of developmental
milestones.
● ICD-11: Disorder of Intellectual Development, Provisional is assigned when there is evidence
of a Disorder of Intellectual Development but the individual is an infant or child under the
age of four, making it difficult to ascertain whether the observed impairments represent a
transient delay. This is sometimes referred to as Global Developmental Delay.

Prevalence:
Intellectual disability has an overall general population prevalence of approximately 1%, and
prevalence rates vary by age. Prevalence for severe intellectual disability is approximately 6 per
1,000.

Development and Course:

● Onset of intellectual disability is in the developmental period. The age and characteristic
features at onset depend on the etiology and severity of brain dysfunction. Delayed motor,
language, and social milestones may be identifiable within the first 2 years of life among
those with more severe intellectual disability, while mild levels may not be identifiable until
school age when difficulty with academic learning becomes apparent.
● All criteria must be fulfilled by history or current presentation. Some children under age 5
years whose presentation will eventually meet criteria for intellectual disability have deficits
that meet criteria for global developmental delay.
● When intellectual disability is associated with a genetic syndrome, there may be a
characteristic physical appearance (as in, e.g., Down syndrome). Some syndromes have a
behavioral phenotype, which refers to specific behaviors that are characteristic of particular
genetic disorder (e.g., Lesch-Nyhan syndrome).
● In acquired forms, the onset may be abrupt following an illness such as meningitis or
encephalitis or head trauma occurring during the developmental period. When intellectual
disability results from a loss of previously acquired cognitive skills, as in severe traumatic
brain injury, the diagnoses of intellectual disability and of a neurocognitive disorder may both
be assigned.
● Although intellectual disability is generally nonprogressive, in certain genetic disorders (e.g.,
Rett syndrome) there are periods of worsening, followed by stabilization, and in others (e.g.,
San Phillippo syndrome) progressive worsening of intellectual function. After early
childhood, the disorder is generally lifelong, although severity levels may change over time.
● The course may be influenced by underlying medical or genetic conditions and co-occurring
conditions (e.g., hearing or visual impairments, epilepsy). Early and ongoing interventions
may improve adaptive functioning throughout childhood and adulthood. In some cases, these
result in significant improvement of intellectual functioning, such that the diagnosis of
intellectual disability is no longer appropriate.
 ● Thus, it is common practice when assessing infants and young children to delay diagnosis of
intellectual disability until after an appropriate course of intervention is provided. For older
children and adults, the extent of support provided may allow for full participation in all
activities of daily living and improved adaptive function.
● Diagnostic assessments must determine whether improved adaptive skills are the result of a
stable, generalized new skill acquisition (in which case the diagnosis of intellectual disability
may no longer be appropriate) or whether the improvement is contingent on the presence of
supports and ongoing interventions (in which case the diagnosis of intellectual disability may
still be appropriate).

Risk and Prognostic Factors:

Genetic and physiological:

Prenatal etiologies include genetic syndromes (e.g., sequence variations or copy number variants
involving one or more genes; chromosomal disorders), inborn errors of metabolism, brain
malformations, maternal disease (including placental disease), and environmental influences (e.g.,
alcohol, other drugs, toxins, teratogens). Perinatal causes include a variety of labor and delivery-
related events leading to neonatal encephalopathy. Postnatal causes include hypoxic ischemic injury,
traumatic brain injury, infections, demyelinating disorders, seizure disorders (e.g., infantile spasms),
severe and chronic social deprivation, and toxic metabolic syndromes and intoxications (e.g., lead,
mercury).

Culture-Related Diagnostic Issues

Intellectual disability occurs in all races and cultures. Cultural sensitivity and knowledge are needed
during assessment, and the individual’s ethnic, cultural, and linguistic background, available
experiences, and adaptive functioning within his or her community and cultural setting must be taken
into account.

Gender-Related Diagnostic Issues:

Overall, males are more likely than females to be diagnosed with both mild (average male:female
ratio 1.6:1) and severe (average male:female ratio 1.2:1) forms of intellectual disability. However,
gender ratios vary widely in reported studies. Sex-linked genetic factors and male vulnerability to
brain insult may account for some of the gender differences.

Language, literacy and speech characteristics:

฀ Learning and Memory:

The learning and memory capabilities of people with intellectual disabilities are significantly
below average in comparison to peers without disabilities. People with intellectual disabilities
develop learning sets at a slower pace than peers without disabilities, and they are deficient in
relating information to new situations (Beirne-Smith, Patton, & Kim, 2006). Children with
intellectual disabilities may not spontaneously use appropriate learning or memory retention
strategies and may have difficulty in realizing the conditions or actions that aid learning and
 memory. However, these strategies can be taught (Fletcher, Huffman, & Bray, 2003; Hunt &
Marshall, 2002; Werts, Wolery, Holocombe, & Gast, 1995; Wolery & Schuster, 1997).

฀ Attention:

To acquire information, children must attend to the learning task for the required length of time
and control distractions. Children with intellectual disabilities may have difficulty in attending to
relevant questions in both learning and social situations (Saunders, 2001). The problem is not that
the student will not pay attention, but rather that the student does not understand or does not filter
the information to get to the salient features (Hunt & Marshall, 2002; Meyen & Skrtic, 1988).

Speech and Language:

People with intellectual disabilities may have delayed speech, language comprehension and
formulation difficulties. Language problems are generally associated with delays in language
development rather than with a bizarre use of language (Beirne-Smith et al., 2006; Moore-
Brown & Montgomery, 2006). People with intellectual disabilities may show delayed
functioning on pragmatic aspects of language, such as turn taking, selecting acceptable topics
for conversation, knowing when to speak knowing when to be silent, and similar contextual
skills (Haring, McCormick, & Haring, 1994; Yoder, Retish, & Wade, 1996). Kaiser (2000)
emphasized that “the overriding goal of language intervention is to increase the functional
communication of students”. The severity of the speech and language problems is positively
correlated with the cause and severity of the intellectual disabilities: the milder the intellectual
disabilities, the less pervasive the language difficulty (Moore-Brown & Montgomery, 2006).

฀ Phonological skills:

o Difficulty in learning to produce speech sounds in their language, consequently

articulation errors are common (approximately 70%)
o Most common phonological processes exhibited by people with ID are reduction of
consonant clusters (kool for school) and deletion of the final consonant (ba for bat).
o Marked weakness in phonological awareness and rhyme detection.

฀ Syntax

o The patterns of syntactic learning may differ, depending upon the severity of
intellectual impairment (Bliss, Allen & Walker-1978)
o The acquisition of the phrase structure appears to follow similar developmental
pattern, even though the rate of learning is significantly different.
 o A difference in clausal syntax development may exist among children with ID but
that it may emerge only in later stages of language acquisition.
o Children with ID tend to comprehend and produce relatively simpler sentences and
have difficulty in comprehending or producing more complex, compound, and less
frequently used syntactic form.
o Difficulty in imitating longer or more complex sentences
o Difficulty to learn more syntactic structures. For instance, they may learn to use the
conjunction “and” relatively easily, but may find it difficult to correctly use “because”
in conversational speech.
o Children with ID may use fewer questions or may substitute “what” questions for all
other kind of questions.

฀ Morphological skills

o Difficulty in producing various grammatic morphemes including:

● Regular plural inflections

● Irregular plurals, although this may be less impaired than regular plural
inflections

● Present progressive-ing forms

● Possessive morphemes

● Regular past tense inflections

● Irregular past tense words; although this may be less impaired than regular
plural inflections

● Third person singular

● Copula and auxiliary

o The irregular forms of plural (e.g., women, men) and past tense (e.g., went, spent) are
learned as whole words, as against the regular plurals (e.g., cups, bags) and regular
past tense (e.g., moved, painted). This differential difficulty may be due to the
children’s greater difficulty in learning smaller morphologic components than whole
word.
o Compared to typically developing children, children with mild intellectual disabilities
master bound morphemes in approximately the same order but at a slower rate
(Newfield & Schalanger-1968)

฀ Semantics
 o Limited vocabulary
o Down syndrome for example, are known to have vocabulary that lacks variety;
although they continue to learn new words, they do so at a slower pace and learn
fewer words than their typical peers (Miller, 1992)
o Children with ID have long been characterized as having concreteness in their
thinking and consequently in their learning and use of vocabulary. One of the clearest
expressions of lexical concreteness is in the comprehension of idioms. Idiom
understanding is significantly poorer in 9-year-old children with mild intellectual
disabilities than in typically developing children of that same age (Ezell & Goldstein,
1991 a)
o Difficulty understanding or producing abstract statements, such as proverbs (Ezell
and Goldstein,1991)
o As with other language skills and concepts, children with ID seems to learn semantic
skills in the same sequence as typical children

฀ Pragmatic skills

o Poor narration skills: children with ID especially those with moderate-severe

cognitive impairment, may be relatively poor narrators of events, experiences and
stories. Children with Parder-willi syndrome, for example, may be unable to retell a
story or answer questions about the story; if they retell a story, they make significant
errors (Lewis et al., 2002; Reily et al.,2004)
o Limited initiation of social exchange: children with significant degrees of ID may be
unwilling or unable to initiate a conversation or any form of social exchange. These
children may respond when spoke to, but often are reluctant to talk first.
o Inadequate topic maintenance: children with ID are less likely to abruptly introduce
to new topics, but this may be due to their difficulty in initiating new topics for
conversation. They do not extend the topic by offering new information. In essence
these children do not play an active role in maintaining topic of conversation.
o Potential difficulties in conversational turn taking
o Limited conversational repair skills: one of the findings of experiments that children
and adolescent with intellectual disabilities do a poor job of repairing breakdowns in
communication. They rarely make requests for clarification when presented with an
inadequate message (Abbeduto, Short-Meyerson, Benson, & Dolish, 1997)

฀ Language comprehension
 o Information processing: individuals with ID require more time to encode incoming
verbal information than nondisabled individuals of equal mental age (Kail, 1992;
Merril &Mar, 1987).
o Linguistic competence: Many (may be 25-50%) but not all children with intellectual
disabilities may have language comprehension difficulties that exceed their cognitive
delays (Abbeduto, Furman & Davies,1989; Miller & Chapman, 1984)
o Contextual understanding: individuals with ID may often function more adequately in
everyday activities than formal testing. Formal evaluation of information processing
or language comprehension may not accurately predict how well children with
intellectual disabilities will comprehend in real situations (Abbeduto & short, 1994).

฀ Academic Achievement:
The cognitive inefficiencies of children with mild to moderate intellectual disabilities lead
to persistent problems in academic achievement (Hughes et al., 2002; Macmillan,
Siperstein, & Gresham, 1996; Quenemoen, Thompson, & Thurlow, 2003; Turnbull et al.,
2004). Children with mild intellectual disabilities are better at decoding words than
comprehending their meaning (Drew & Hardman, 2007) and read below their own
mental-age level (Katims, 2000). Children with intellectual disabilities may be able to
learn basic computations, but may be unable to apply concepts appropriately in a
problem-solving situation (Beirne-Smith et al., 2006). A growing body of research has
indicated that children with moderate or severe intellectual disabilities can be taught
academics as a means to gain information, participate in social settings, increase their
orientation and mobility, and make choices (Browder, Ahlgrim-Delzell, Courtad-Little, &
Snell, 2006).

ASSESSMENT OF ID:

Assessment includes;

o Intellectual assessment
o Adaptive skill assessment
o Educational assessment
o Speech and language assessment

1)Intellectual Assessment:
Intellectual ability is measured using standardized cognitive assessments, resulting an IQ score. IQ
was originally defined as a ratio of one’s mental age to the chronological age, but the ratio of IQ has
been replaced by a more complicated deviation IQ (Brue & Wilmshurst, 2016).

฀ Cognitive measures typically assess a variety of areas including verbal knowledge, spatial
skills, processing/psychomotor speed, memory, and verbal and non-verbal reasoning abilities
(Sattler,2008).

฀ Early childhood assessment:

In young children, clinicians may choose to obtain a developmental quotient (DQ) instead of
an IQ score,
DQ= developmental age
Chronological age
As IQ is unstable in childhood, using a DQ quantify strength and weakness related to
developmental milestones may be more precise and clinically useful in young childhood
(Matson, Mahan, Hess & Fodstad, 2010)
- The Bayley Scales of Infant and Toddler Development-Third Edition (Bayley-3; Bayley,
2006).
- Mullen Scale of Early Learning (Mullen; Mullen, 1995)
- Battelle Developmental Inventory-Second Edition (BDI-2, Newborg, 2005)
- Differential Abilities Scale, Second Edition-Early years Battery (DAS-2; Elliot, 2007)
-Wechsler Preschool and Primary Scale of Intelligence- fourth Edition (WPPSI-1V
Wechsler,2012)

฀ School -aged to adulthood:

-The Wechsler Intelligence Scale for Children (WISC-V; Wechsler, 2014)
-Stanford-Binet Intelligence Scale-Fifth Edition (SB5; Roid, 2003)
-DAS-11 School-Age-Battery (Elliott, 2007)

2) Adaptive skill Assessment:

Adaptive deficits across conceptual, social, and practical domains should also be measured using
standardized, norm-referenced assessments. Standardized measure provides the age-referenced results
necessary for evaluating an individual’s degree of impairment against what is expected (Cervantes &
Jang, 2016; Schalock & Luckasson, 2004).

-Vineland Adaptive Behavior Scales, Third Edition (Vineland-3)

-Adaptive Behavior Assessment System, Third Edition (ABAS-3; Harrison & Oakland, 2015)
3)Speech and Language Assessment:

Assessment of language disorders in children include both standard and special procedures. Most of
these typical and standard procedures of assessment are adapted to concentrate on the child’s
language skills. The standard procedures include;

❖ Case history:

✔ Interview: The clinician structures the interview to get more specific information on the
child’s language development and the potential risk factors the child may have been
exposed to. If the child belongs to an ethnocultural minority group, the standard interview
schedule may be further modified to seek information on the dialectal, bilingual, and
bicultural status of the child and family.

✔ Case history taken through:

● Parental interview

● Observation of the parent-child, child-child interaction during play and other

situations

● Direct interaction with the child

● Information from other professionals

✔ Case history should include

● Demographic history

● Language used by the child

● Brief history about the problem

● Prenatal, perinatal and postnatal history

● Family history

● Medical history

● Developmental history (motor, sensory, speech and language and social)

● Behavioral history

● Educational history

● Comprehension and expression- verbal and non-verbal

● Reading, writing and arithmetic skills

 ● Articulation

● Fluency

● Voice

● Suprasegmental (stress, intonation and rhythm)

❖ Oro facial examination

❖ Administration of standardized tests:

Criteria for selection of standardized tests:

● Detailed and comprehensive test manual

● Based on a large and diverse normative data

● Sample skill adequacy

● Recently revised and thus provides current normative data

● Strong reliability and validity

● Appropriate stimulus items

● Select a test that will yield useful diagnostic information and help design treatment.

฀ Receptive–Expressive Emergent Language Test–Fourth Edition (REEL-4)

● Age range:0-3 years

● designed to identify infants and toddlers who have language impairments or who
have other disabilities that affect language development.

● It is especially useful as an assessment and planning instrument in Early Childhood

Intervention programs.

● The REEL-4 has two subtests that make up the Language Ability composite,
Receptive Language and Expressive Language.
 ● Results are obtained from a caregiver interview and direct observation.

฀ PPVT (Peabody Picture Vocabulary Test)-1V edition -2007

● Given by Lloyd M Dunn & Douglas M Dunn

● Age range-2.6 year to 90 years and older

● Examinees see a page with four-color pictures. For each item, the examiner says a
word, and the examinee responds by selecting one picture out of four that best
illustrates that word’s meaning. Because the examinee points to the appropriate item,
the test requires no reading, writing, or expressive verbal language, and it can be used
with non-readers and those without fluent verbal abilities.

● the PPVT contains 228 items, divided into 19 “sets” of 12 items each; an examinee
completes all items within a set. The basal level is set when an examinee correctly
responds to 11 or more items in a set; the ceiling is established as the set where an
examinee makes eight or more errors.

฀ Communication DEALL Developmental Checklist (CDDC)

● The Communication DEALL Developmental Checklist (CDDC) was developed by

Karanth (2007), to assess developmental skills of children up to the age of 6 years,

● eight developmental domains, with norms based on an Indian population, include

social skill, emotional skills, cognitive skills, gross and fine motor skills, receptive
and expressive language skills, and activities of daily living.

● 4point rating scale.

฀ Comprehensive Language assessment Tool for Children [CLAT]

● (Navitha. U & Dr. Shyamala K C (2009)

● Age range: 3-6 Years

● The main domains include Receptive, Expressive and Cognitive skills.

● This test involves 5 age groups ranging from (3-3.6y, 3.6-4y, 4-4.6y, 4.6-5y, 5-6y).

● After the test is been administered, the language score obtained and are compared
with the Normal Mean values and the interpretation is made.
 ฀ Linguistic Profile Test (LPT- Pratibha karanth)

฀ 3D-LAT (Geetha Harlekar-1986)

● Age range-9 months to 3 years

● 9 groups, each group has a range for 4 months

● The test includes 27 items under each section- the reception, expression and cognition
with three items from these for every age group.

Screening tools

฀ Developmental Screening Test (DST) by Bharat Raj is a widely used screening tool by
professionals.

● It is a designed to measure mental development of children from birth to 15years

of age.

● Semi-structured interview with the child and a parent / caregiver.

● 88 items distributed across age.

● 4 developmental areas – Motor development, adaptive behavior, language

development and personal – social behavior

● It provides Developmental Age (DA) and developmental quotient (DQ)

฀ Functional Assessment Check List for Programming (FACP) – Vijayalakshmi Myreddy,

Jayanthi Narayanan, 1991.

● Domains assessed:
Self help skills - drinking skills, toileting skills, drinking skills
Motor skills
Communication skills
Social skills
Visual skills

● The items are scored according to how well the child is able to perform in a
particular skill.

● “+” - Yes, “-” – No, “C” – Occasional cues, “NE” – No exposure, “VP”-
Verbal prompting, “GP” – Gestural prompting, “M” – Modeling and “PP” –
Physical prompting.
 ● It also provides a checklist of problem behaviors that includes – self injurious
behaviors, inappropriate emotions, etc.

฀ The revised Madras Developmental Program System Behavioral Scale MDPS-A curriculum-
based assessment checklist (1975) is suitable for identification purposes. – Jayachandran,
Vimala (1975).

● Comprehensive behavioral tool that can be used for any age, sex and level of
retardation.

● 18 domains – each 20 times (total – 360 items), sequentially arranged according

to normal development.

● Domains include – gross motor, fine motor, meal time activities, dressing,
grooming, toileting, receptive language, expressive language, social interaction,
reading, writing, numbers, time, money, domestic activities, community
orientation, recreation, vocational.

● Scoring – If the child has the skill mentioned in the particular item, it is marked
with A / shaded in Blue. If the child fails in an item, it is marked with B/ shaded
in Red.

฀ Denver Developmental Screening Test (Frankensberg, Dodds and Fandal).

● Identify young children, up to age six, with developmental problems.

Domains assessed – Cognitive skills, language skills, fine motor skills, gross
motor skills, social skills, self mastery skills.

฀ The Communication DEALL Developmental Checklist (CDDC) – Pratibha Karanth, 2007

● The Communication DEALL Developmental Checklist (CDDC) assess

developmental skills of children up to the age of 6 years.

● 8 developmental domains, with norms based on an Indian population, include

social skill, emotional skills, cognitive skills, gross and fine motor skills,
receptive and expressive language skills, and activities of daily living.

● 4 point rating scale.

฀ Behavioural assessment scale for Indian Children with Mental Retardation (BASIC – MR): -
Rita Peshawars, Venkatesan.

● It consists of two parts – Part A, Part B.

Part A – Deal with skills behavior:
 o Motor
o Activities of daily living
o Language
o Number
o Reading
o Domestic – social
o Pre vocational
● Part B – Deal with undesirable behavior:
o Violent and distractive behavior.
o Temper tantrums
o Misbehavior with others
o Self injurious behavior
o Repetitive behavior
o Odd behavior
o Hyper activity
o Rebellious behavior
o Anti social behavior

Administration of alternative assessment procedures:

The clinician can make a functional behavioural assessment, devise client specific or criterion
referenced procedures (e.g., tell a story the child retells, ask the child to narrate a personal
experience, read his/her favourite book)

Post assessment counselling:

The clinician should counsel the patients about the assessment results, make
recommendations, discuss about the rehabilitation options and prognosis, and answer
questions about language disorder and treatment options.

Intellectual assessment:

Intellectual ability is measured using standardized cognitive assessments, resulting an IQ score. IQ

was originally defined as a ratio of one’s mental age to the chronological age, but the ratio of IQ has
been replaced by a more complicated deviation IQ (Brue & Wilmshurst, 2016).
Cognitive measures typically assess a variety of areas including verbal knowledge, spatial skills,
processing/psychomotor speed, memory, and verbal and non-verbal reasoning abilities (Sattler,2008).
Early childhood assessment:
In young children, clinicians may choose to obtain a developmental quotient (DQ) instead of an IQ
score,
DQ= developmental age/Chronological age
As IQ is unstable in childhood, using a DQ quantify strength and weakness related to developmental
milestones may be more precise and clinically useful in young childhood (Matson, Mahan, Hess &
Fodstad, 2010)
- The Bayley Scales of Infant and Toddler Development-Third Edition (Bayley-3; Bayley, 2006).
- Mullen Scale of Early Learning (Mullen; Mullen, 1995)
- Battelle Developmental Inventory-Second Edition (BDI-2, Newborg, 2005)
- Differential Abilities Scale, Second Edition-Early years Battery (DAS-2; Elliot, 2007)
- Wechsler Preschool and Primary Scale of Intelligence- fourth Edition (WPPSI-1V Wechsler,2012)
School -aged to adulthood:
-The Wechsler Intelligence Scale for Children (WISC-V; Wechsler, 2014)
-Stanford-Binet Intelligence Scale-Fifth Edition (SB5; Roid, 2003)

Adaptive skill assessment:

Adaptive deficits across conceptual, social, and practical domains should also be measured using
standardized, norm-referenced assessments. Standardized measure provides the age-referenced results
necessary for evaluating an individual’s degree of impairment against what is expected (Cervantes &
Jang, 2016; Schalock & Luckasson, 2004).

-Vineland Adaptive Behavior Scales, Third Edition (Vineland-3): standardized assessment tool that
utilizes semi-structured interview to measure adaptive behavior and support the diagnosis of
intellectual and developmental disabilities and developmental delays.

-Adaptive Behavior Assessment System, Third Edition (ABAS-3; Harrison & Oakland, 2015): The
ABAS-3 covers three broad adaptive domains: Conceptual, Social, and Practical. Within these
domains, the ABAS-3 assesses 11 adaptive skill areas (each form assesses 9 or 10 skill areas based on
age range). Items focus on practical, everyday activities required to function, meet environmental
demands, care for oneself, and interact with others effectively and independently.

Vocational assessment:

Vocational assessment can be broadly defined as the “process of obtaining information about a
worker’s skills and performance in order to make appropriate training decisions” (Bellamy, Horner
and Inam, 1979)

It is a comprehensive process that utilizes work, real or simulated as the focal point for assessment
and vocational exploration, the purpose of which is to assist individuals in vocational development.
Vocational assessment needs to address four major issues, namely:
Eligibility for services
Vocational potential – which involves intellectual ability assessment, academic achievement,
aptitudes and interests.
Social adaptation and level of psychological and emotional functioning
Evidence of problems that require treatment.

MANAGEMENT
General Principles for treatment of children with Language disorders

Use family-centered and culturally appropriate practices.

● A child’s immediate environment plays an important role in learning & development of the
child.
● Clinicians should ensure parents are aware about the conditions, its possible effect/ domains
affected and what are the future directions.
● Treatment should extend beyond the therapy room.

Form collaborative teams.

● Speech language pathologists should work in group with different professionals to outline a
best plan of action & appropriate goals and goal attack stratergies, depending on the strength
& weakness of the child.
● The most contemporary approach to collaboration is the concept of Interprofessional
education/Interprofessional practice (IPE/IPP), where multiple service providers learn from
each other and work together to provide comprehensive, high-quality services.

Follow a strength-based perspective.

A strength based perspective should be considered in teaching linguistic skills , so that the child learns
easily & becomes capable of using these new skills easily . (American Association of Intellectual and
Developmental Disabilities [AAIDD], 2013. We try to understand challenges, aknowledge them &
keep a positive attitude, thinking about what can be done rather than what not, thus helping the child
to achieve positive outcomes from the therapy

Maximize self-sufficiency.
● The need to develop and maintain functional communication to maximize self-sufficiency in
individuals with language disorders is important, this helps in building confidence &
independency.
● SLPs play an important role in promoting communication abilities that further the
independence and self-advocacy of persons with various language disorders.
Recognize individual variability.

● SLP should keep in mind each child with a language disorder is a unique indivijual with
his/her own identity.
● Behavioral profiles across individuals or even etiologies are not similar or predictable from
the diagnostic category (e.g., Dykens, Hodapp, & Finucane, 2000).
● Each individual has his or her own personal likes, dislikes, strengths, and needs, and these can
change over time and across living environments (Zigler, 2001). These facts should be kept in
mind while planning goals & activities.

Foster a community environment of respect and inclusion.

● Community based activities helps individual to actually use the language with a different
number of individuals, learn about their strengths & weaknesses , correct their mistakes and
improve further.
● Just because kids with special needs do things differently or may take more time, we
shouldn’t be thinking it as a weakness, instead we should provide & promote an environment
where they feel accepted and appreciated for what they are.

Involve peers as communication partners.

● It’s a known fact kids learn a lot from their peers much better & easily.
● They are taught to initiate and respond as persistent communication partners as well as to
serve as models for appropriate communication skills (Goldstein, English, Shafer, &
Kaczmarek, 1997; Guralnick & Paul-Brown, 1989; Paul-Brown & Caperton, 2001) and use
learned strategies to effectively promote social communication in classmates with ID
(Goldstein & Cisar, 1992; Guralnick, 1990, 1994; Strain & Kohler, 1998).

Evidence Based Practice –

The approaches & therapy techniques used should be based up on the contemporary research.

Clinical expertise/expert opinion-

The knowledge, judgment, and critical reasoning acquired by clinician via training and professional
experiences on a daily basis.

Evidence (external and internal)-

The best available information gathered from the scientific literature (external evidence) and from
data and observations collected on your individual client (internal evidence)

Client/patient/caregiver perspectives-The unique set of personal and cultural circumstances, values,

priorities, and expectations identified by your client and their caregivers
Management of children with intellectual disability

Implications for interventions – Each child with ID presents a unique pattern of communicative
strength & weakneses that must be identified as a result of a through indivijual assessment. As an
overarching principle, intervention shold compromise a comprehensive assessment & a flexible and
functional intervention plan , emphasizing the child’s strength to address specific communicative-
linguistic needs that are derived from the case history , previous evaluations, parent feedback &
teacher input ( kumin 2008). The words functional & flexible are particularly central to intervention
of these children . Goal and objectives of intervention need to have at their core the functional
application of language , literacy & communication .Also these goals should be flexible to meet these
functional aspects and should be modified acoording to the changing communicative need of the
client .

1.What is unique about children with ID?

Normally the therapy techniques used with various kids who have language impairements tends to be
adapted to address the communication needs of those children with ID. But the following facts are to
be kept in mind while doing so:

a. A need for repetition –Language & literacy learning opportunities should be more
intensive and ongoing & to occur more frequently becaue children with ID needs many
more exemplars to make these decisions. Yoder et al (2014) reported that daily
communication & language intervention in children with DS resulted in superior
vocabulary following 9 months of intervention.

b. Intervention occurring in naturalistic environments-Children with ID benefit from

language and literacy intervention that use naturalistic & concrete examples. A number of
studies have shown that children with ID when given training in real classroom situations
showing good improvements in performance .( schreibman et al 2015, Hansen,
wadsworth , Roberts & poole 2015) . Milieu teaching (Kaiser & Roberts ) is one such
example which encourages communication partner to follow the child’s lead , prompt and
model specific language skills within the context of daily routines & activities and has
been effective in language and literacy learning.

c. A need to plan for generalization – As children with ID are concrete learners , they have
many difficulties in generalizing skills targeted in direct teaching settings to environments
outside the settings in which the skills were learned. Generaliztion is more likely to occur
 when the same concept is practiced across multiple contexts such as home, classroom etc.
Parents , other caregivers as well as teachers play an important role in this. ( Rakap &
Rakap 2014, Kaiser 2014). Further more , learning theory suggests that skills are
generalized better when learned in situations where they are supposed to be used.
Inclusive models where the child receive intervention services in their general classrooms
or resource rooms may be more appropriate ( Zurawaski 2014).

d. Addressing the learned helplessness & poor decision making of children with ID- An
unfortunate reality is that children with ID experience frequent failures. As a result, these
children might adopt an approach to responding to requests or making de cisions that is
referred to as learned helplessness. They may also be reticent to initiate interactions.
These characteristics reflect those of a passive communicator. Children may not do things
or participate in interactions even though they know how (Bybee & Zigler, 1999).
According to Jenkinson (1999), learned helplessness and poor decision making are
related, and children with ID tend to make poor decisions. When making decisions, they
may tend to rely on a limited number of solutions and apply those solutions to new
situations inflexibly. Another Issue related to decision making presents when children
with ID approach multi-step processes. The limited success they tend to experience at
each stage appears to result from falling to have a complete comprehension of decision
situations, generating few alternative solutions, faling to anticipate the possible negative
consequences of a course of action, and not selecting an appropriate course of action
(Khemka & Hickson, 2006).
These failures can contribute not just to reinforcement of learned helplessness but to
negative self-Images, increasing resistance to trying, and a higher likelihood of being
motivated by extrinsic factors, such as ease, comfort, avoidance of stress, security, health,
external rewards, and avoidance of failure (Tassé & Havercamp, 2006). Therefore, in
order to facilitate successful Inclusion of adolescents and adults with ID In community
and work environments, intervention must explicitly address decision-making skills
(Khemka & Hickson, 2006), promote appropriate assertiveness and considered responses
to requests, and avoid unintentionally reinforcing learned helplessness.

What Materials Are Appropriate for Children with ID?

Practical consideration in planning an Intervention procedure is selecting material that will

engage children's attention and motivate them to participate in the designed ties for the
selected intervention objective. In this regard, we recall that children are often delayed in
areas of development other than language and communication in sensory and motor
development and social skills, combined with cognitive impairment make it difficult to
predict a child's interest with a particular toy or activity. Neither MA or CA provides a
guidance as to what will be the child's interest. Nevertheless, a child level of ID can provide a
guide to materials and activity selection.

There may be an advantage in initially using materials that are as concrete and real as
possible. Remembering that children with ID tend to be concrete bound learners, objects in
real situations may be the more effective materials and activities. For example, instead of
using pictures of books, real books are more likely to increase understanding of what books
are for and how they are handled. Similarly, for adolescents with ID, rather than than only
 talking about how to use public transportation, having the adolescents experience using public
transportation while providing feedback and guidance on the decision-making skills involved
in the process is likely more effective. The language necessary for fulfilling the activity is
embedded into and practiced during repeated executions of the activity. Coaching and
mentoring caregivers and teachers in materials and activity selection are also important ways
to incorporate increased learning opportunities and generalization strategies into intervention
plans.

What Goals Are Appropriate for Addressing Intelligibility?

Because a high percentage of children with ID also have difficulties with speech production,
it is important to consider if articulatory and/or phonological impairments will hinder efforts
to change other aspects of language and if improving intelligibility might allow children to
display more linguistic abilities, enhance conversational interaction, and promote faster
language learning.
We should always keep in mind that language production teaching requires us to judge
children's attempts at target forms. If those attempts are unintelligible, we are often unable to
reinforce or even respond appropriately, under these circumstances, language Intervention
will languish.
Phonological approaches to treatment have been widely recommended and research results
have shown improved intelligibility post-treatment. Barnes and colleagues (Barnes et al.
2009) suggest the cycles approach (Hodson, 2006) and the complexity approach
(Glerut,2001, 2005).
Importantly, the goal of intervention is to improve speech intelligibility, not to eliminate all
errors.
Following phonological/articulation intervention, children might still have some speech
errors.

Approaches to intervention

Direct and Indirect Intervention:

Direct intervention Indirect intervention

SLP plays the major role
Professional plans the goals, means to achieve it
and involves in direct interaction with the child .
The SLP directly measures the outcomes of the
treatment targets .
Parents or teachers will have limited roles
SLP has a supportive role
Professional along with parents & teachers
decides goals and the attack strategies
SLP doesn’t directly involve in interaction with
the child & it involves more of environmental
modifications etc.
Parents play principle role.

Group and Individual intervention :

Individual intervention Group intervention

One to one among client and clinician Clinician & few clients
Few distractions and defined targets Chances for more distractions
Typically smaller children Typically older children & adolescents
Early language skill acquisition Later linguistic skill acquisition
 Less communication contexts and interactions More communication context & interactions
Specific skill acquisition More practice and generalization skills.

Service delivery models – This refers to where, when and with whom the language intervention takes
place. Traditionally , we think of it as language intervention taking place in a clinic room with the
clinician providing therapy to the child or a group of children for 45-60 minutes sessions each week.
This often called as pull out form of service delivery .

1. The consultant model – The SLP acts as a consultant in this form, where he determines the
goals and activities but doesn’t implement them by himself. The caregiver or teachers may be
actually carrying out the activities and will be meeting the SLP on a regular basis to provide
feedback on intervention process , discuss problems that arise, and plan further intervention
targets and activities . When acting in consultant role , the SLP remains responsible for
evaluating the clients progress in the intervention program ,for deciding the targets have been
met , and for trouble shooting the intervention procedure and the contexts to ensure that are
effective . One study by Girolametto & Weitzman (2006) reviewed research showing that
parents can be trained to use focused stimulation that results in positive changes in the
language form & content.

2. The language based class-room model- Here the clinician is the classroom teacher for a
group of students with language disorders. For school-age client, language-based classroom
instruction may comprise either the entire school day or part of the day , depending on the
severity of the students need. The SLP provides instructin for each client, according to his or
her individual Eductional Plan ( IEP)and also organizes activities that focus on oral language
skills for the group. For adolescents with language disorders , the language-based classroom
model often takes the form of one of the student’s classes.

3. Collaborative model- Midway between the consultant and language based classroom model ,
in terms of intensity of the client contact , is the collaborative model. SLP works with one or
more students who have been identified as having a language disorder, but does o in the
mainstream classroom in collaboration with the regular teacher. This model too can be
implemented at any developmental level, from preschool through adolescence.

Treatment techniques

Fey (1986) –discussed a continuum of naturalness in intervention approaches. This continuum

represents the extent to which the settings & activities in intervention resemble “real life “or the world
outside the clinic room. Activities in language intervention can be a lot like the activities a child
engages in during the rest of his or her life, or they can be very different.
The clinician-directed Approachs–
● In these approaches, the clinician specifies material to be used , how the client will use them,
the type and frequency of reinforcement , the form of responses to be accepted as correct , and
the order of activities – in short , all aspects of the intervention .
● Clinician- directed ( CD) approaches , also referred to as drill ( shriberg & Kwiatkowski ,
1982) or discrete trail intervention ( DTI) , attempt to make the relavant linguistic stimuli
highly salient , to reduce or eliminate irrelevant stimuli , to provide clear reinforcement to
increase the frequency of desired language behaviours and to control the clinical environment
so that the intervention is optimally efficient in changing language behavior.
● An advantage of CD approaches is that they allow the clinician to maximize the opportunities
for a child to produce a new form , producing a higher number of target responses per unit
time than other approaches .
● Proponents include Fey & proctor Williams 2000, Connell 1987 etc.
● The proponents points out that the un-naturalness of this approach itself is an advantage for it.
The fact that for what ever reason the child has failed to learn language through natural
interactions suggest that something else is necessary .This something else in this view is
nothing but a highly structured clinician controlled , tangibly reinforced context of the
behaviorist intervention.
● It seems while CD approaches are highly efficient in helping children to produce new
language forms , they are not so effective in getting them to incorporate these forms into the
real communication outside the clinical settings.
● Lets looks at 3 major varieties of CD activities : Drill , drill play & modeling.

Drill –Drill is most highly structured in their frame works . The clinician instructs the client
what the expected response is & provides a training stimulus such as word or phrase to be
repeated. Stimuli is carefully planned & coordinated. If prompts are used they are gradually
faded . When prompts are given child is expected to give responses the clinician intended and
if that’s the case the child is reinforced with some tangible reinforcement and verbal praises.
If the child gives a response that’s not intended , The clinician tries to shape the utterance into
more meaningful things, so that the complete correct response comes from the part of the
client later on.
Drill is a most efficient intervention in that it provides the highest rate of stimulus
presentations & client response per unit time. The problem with drill is neither clinician nor
the child liked it very much due to the higher number of repetition and trails involved in it.

Drill play – Its also a CD approach similar to drill, but the difference between both is that it
attempts to give some motivation into the drill structure. This is done by adding an antecedent
motivating event , that is , one that occurs not only after the target response but also before its
even elicited. There will be two motivating events-Antecedent motivating event and
subsequent motivating event , that is after reinforcement is given. Drill & drill play are said to
be equally effective in eliciting efficient improvements in phonological intervention.

Modeling –Modeling has its basis in the social interaction theory .It uses a third person as
model .Modeling uses highly structured format , extrinsic reinforcement and formal
interaction contexts. The child is never expected to imitate what the clinician says rather he is
expected to find some similar patterns across various stimuli that is presented to him.

The child centered approaches ( Indirect language stimulation )

● In arranging a CC approach , a clinician arranges an activity so that opportunities for the
client to provide target responses occur as natural part of play and interaction.
 ● There are no tangible reinforcers, no requirements that the child provides a response to
clinicians language and no prompts or shaping the incorrect responses when they occur.
● CC intervention puts the child in drivers seat.
● We follow the childs lead and do what she wants to do or talk about what he or she wants to.
● Clients engaged in a CC activity spend their time in natural, enjoyable play with a very
accepting and responsive adult who makes a consistent and salient match between what they
are doing and the language used to talk about it.
● It includes methods like – Self talk, parallel talk , imitations , Expansions, extensions ,
Recasting etc.

Self talk & parallel talk- In self-talk we describe our own actions as we engage in parallel
play with the child. If the child is playing with block, get your own blocks and start building ,
saying as we do , “ I’m building .I’m building tower , see my blocks, I’m building the next
layer.
In comparison , parallel talk we provide self talk for the child.Instead of talking about what
we do, we do a running commentary of what the child does. Consider the following example ,
“You are building, you are building the house. See you put an another block. Oh your house
is big. Your house is blue etc.”
Both self-talk and parallel talk are helpful for children who doesn’t talk in clinical settings
.The expectation is the use of these techniques maximizes the chances that the child will use
the model in producing a spontaneous utterances.

Imitations-We often ask children to imitate what we say in intervention. But instead , we can
turn the tables and imitate what the child says .Folger and chapman (1978) showed that adults
often repeat what normal toddlers say and that when they do, there is a substantial probability
that the children who imitate the imitation.If the child repeats our imitation , we can go on to
use some of the other forms of contigent responses available in indirect language stimulation
to provide more focused and extensive feed back.

Expansions- In expanding the child’s utterances we can take what the child said and add the
grammatical markers and semantic details that would make it an acceptable adult utterance.
Eg- If the child puts a toy dog in a dog house and says ‘doggy’ or ‘doggy house’ , this could
be expanded as ‘The doggy is in the house’.

Extensions- Some authors calls it as expatiations. They are comments that add some semantic
information to a remark made by the child.
Eg- The doggy is in the house and sleeping .

Recasts – They are similar to expansions . In recasting we expand the child’s remark into a
different type or more elaborated sentence.
Eg-So if the child says ‘ doggy house’ , we can recast it as a question , ‘ is the doggy is inside
the house’ or a negative sentence ‘ the doggy is not inside the house ‘ etc.

Hybrid Approaches –
● Unlike CC approaches , hybrid approaches target one or a small set of specific language goals
.
● Clinician maintains a good deal of control in selecting activities and materials but does so in a
way that consciously tempts the child to make spontaneous use of utterences of the types
being targeted.
 ● The clinician uses linguistic stimuli not just to respond to the child’s communication but to
model & highlight the forms being targeted.
● It includes approaches like Focused stimulation, vertical structuring ,Milieu teaching etc.

Focused stimulation – In focused stimulation the clinician carefully arranges the contexts of
interaction so that the child is tempted to produce the utterance with obligatory contexts for the forms
being targeted. He also provides very high density models of the target. The child is not required to
produce , but only tempted to do so. Weismer & Robertson (2006) did extensive reviews of FS to
teach form , content for both monolingual and bilingual children , when implemented by clinicians &
parents , & for improving functional comprehension & use of target structures.

Incidental teaching:

● A technique that helps to teach elaborated language productions in children who

independently initiate a communicative interaction with an adult
● In incidental teaching, the adult waits for the child to initiate a topic, prompts the child’s
elaboration of language ,and then provides the reinforcer specified by the child’s initiation
(Hart & Risley ,1975)

Steps involved in Incidental teaching of Oral communication skills include:

1) When a child initiates an interaction, the adult gives the child full attention ,creating joint
focus of attention on the child initiated topic.
2) The adult asks for language elaboration (eg: what do you want? )
3) If the child does not elaborate, the adult provides a further prompt. If the expected response
has not been previously observed in the child’s language repertoire, the adult provides full
model of an appropriate elaboration for the child to imitate.
4) When the child provides a language elaboration, either spontaneously or in response to a
prompt, the adult reinforces the utterance verbally or gives the child the desired object. (eg .
the child gets chocolate)

Joint Action Routines:

● Joint action routines is also known as Script therapy.

● The idea behind joint action routines is to create interactive, systematic repetitions of
events in which each partner has predictable language and behavioral patterns to
complete.
● The routines can reflect usual events in child’s environment, or they can be created.
(Constable, 1986 ; Dekroon et al., 2002; Kim & Lombardino,1991) .
● They focus on the specific topic or themes, such as craft activities in which the child has to
ask for needed materials, or they may be centered around pretend paly routines.
● Joint action routines are supposed to reduce demands on a child so that the child can focus on
the language tasks required (Ellis Weismer, 2000).
● As the child becomes familiar with specific routines, the expectations for language are
gradually change to more advanced skills.
 ● A problem with the joint action routine method of language teaching is the manner in which
the routines are or are not modified to increase the level of language expected from a child
and the strategies employed to elicit the higher level language behaviors.
● Generalizing the routines to novel situations can sometimes also be problematic.

Functional communication training (FCT)

● The functional communication training approach is a behavioral intervention used to

replace an individual’s maladaptive or problem behaviors( eg. Tantrums, hitting, self-
injury )
● The FCT approach was developed in the 1980s .

● The steps for implementation of FCT include :

1) Identify the antecedent stimuli (i.e time of day, people, activities, settings) that trigger
the maladaptive behavior.
2) Determine the purpose of the maladaptive behavior and the reinforcement that is
sustaining inappropriate behaviors via a functional analysis include a) manipulating
task demands by altering the discriminative stimuli, such as making the task easier
or more difficult; and b) changing the reinforcement schedule by presenting and
withdrawing the reinforcement while documenting behavior changes.
3) Identify a communicative behavior equivalent to the maladaptive behavior ( eg. Use
of a sign , gesture, pointing response, vocalization) that will permit the individual to
obtain the desired reinforcement. The communication response needs to be as easy as
, or easier than the maladaptive behavior .
4) Monitor the generalization and use of the communication skill across situations.
(Bailey et al., 2002; Carr et al., 2004)

● Originally FCT was used with non-verbal individuals, and the communicative
replacement behaviors typically were signed, gestured, or implemented via augmentative
communication.
● At present , individuals with Autism, people with varying levels of ID, and individuals
who are verbal are considered viable FCT candidates ( Halle, Ostrosky, & Hemmeter,
2006)
● Problem behaviors can be eliminated through extinction and replaced with alternate, more
appropriate forms of communicating needs or wants.
● FCT can be used across a range of ages and regardless of cognitive level or expressive
communication abilities (E. G. Carr & Durand, 1985).
● An FCT approach has been used with students with ID to replace challenging behaviors
with appropriate communication alternatives (Brady & Halle, 1997; Martin, Drasgow,
Halle, & Brucker, 2005; Schmidt, Drasgow, Halle, Martin, & Bliss, 2014).
.

Pivotal response training:

● Pivotal Response Treatment® is a naturalistic intervention model derived from ABA
approaches. Rather than targeting individual behaviors one at a time, PRT® targets
pivotal areas of a child's development, such as motivation, responsivity to multiple
cues, self-management, and social initiations.
 ● By targeting these critical areas, PRT® results in widespread, collateral improvements in
other social, communicative, and behavioral areas that are not specifically targeted.

● The underlying motivational strategies of PRT® are incorporated throughout intervention

as often as possible. These include child choice, task variation, interspersing maintenance
tasks, rewarding attempts, and the use of direct and natural reinforces.

● The child plays a crucial role in determining the activities and objects that will be used in
the PRT® exchange. Intentful attempts at the target behavior are rewarded with a natural
reinforcer (e.g, if a child attempts a request for a stuffed animal, the child receives the
animal, not a piece of candy or other unrelated reinforcer).

● Pivotal Response Treatment® is used to teach language, decrease disruptive/self-

stimulatory behaviors, and increase social, communication, and academic skills.

IT’S FUN PROGRAM

The IT’s fun program (Rosin,2006; Rosin & Miolo, 2005) is a performance –based intervention
designed to emphasize the communicative strengths( i.e. social skills, visual processing , receptive
language ) of school aged child with DS and to facilitate improvement in areas of deficit.

● Professionals use specific strategies to increase participants verbal output, vocabulary

development and literacy skills.
● For example language facilitators 1) Incorporate visual supports (words, pictures, and symbols) to
help participants learn song lyrics and lines for the plays 2) prompt participants to use
metacognitive strategies to improve verbal production and organize information eg. Using
pictures, symbols, or a few words as a reminder) 3) use scripts and routines to increase fluency
and verbal output.
● The participants also are trained to use strategies such as body movement, gestures, and singing to
facilitate verbalization. Some “rules and tools “ guiding their performance include 1) talking
slowly ,2) saying all the sounds in words, 3) projecting their voices, and 4) formulating messages
before speaking .
● Dance and movement activities are used to increase and vary vocal quality and enhance the
participants, fun and motivation.
● Evidence supporting the IT’s Fun Program; Rosin and Miolo (2005) report pre and post
intervention data for seven children with DS between the age range of 5-12 years.
● The seven participants demonstrated improved communication and social skills and showed
improved attitudes about talking following the 3-week intervention.

Play therapy:
● Play therapy is widely used to treat children’s emotional and behavioral problems. Play therapy is
a structured, theoretically based approach According to Jean Piaget, "play provides the child
with the live, dynamic, individual language indispensable for the expression of [the child’s]
subjective feelings for which collective language alone is inadequate.
● Play therapy is a form of counseling or psychotherapy that uses play to communicate with and
help people, especially children, to prevent or resolve psychosocial challenges. This is thought to
help them towards better social integration, growth and development, emotional modulation.
RECENT WORKS:

The association between expressive language skills and adaptive behaviour in individuals with
Down syndrome
Laura del Hoyo Soriano, Jennifer Catalina Villarreal, Audra Sterling, Jamie Edgin, Elizabeth
Berry‑Kravis, Debra R. Hamilton, Angela John Thurman & Leonard Abbeduto
Goal - to determine whether expressive language skills contribute to adaptive behavior (e.g.,
socialization and daily living skills) in children, adolescents, and young adults with Down syndrome
(DS).

฀ Examining the relationships between specific aspects of adaptive behavior (i.e., socialization
and daily living skills) and specific aspects of expressive language (e.g., syntax, vocabulary,
intelligibility) can help identify the language skills to be targeted in interventions designed to
support greater independent functioning in those with DS.
Methods: A total of 95 participants with DS between the ages of 7 and 23 years were included in the
current study.

Inclusion criteria - medical documentation of DS (i.e., trisomy 21 or translocation) without

mosaicism; IQ criteria for ID (IQ ≤ 70); use speech as the primary mode of communication, with
English as their primary language
Expressive language was assessed using the Expressive Language Sampling (ELS) conversation and
narration procedures. The language produced was transcribed and analyzed to yield measures of
expressive vocabulary, syntax, and intelligibility.
Socialization and daily living skills of participants with DS were measured with the Vineland
Adaptive Behavior Scales, 2nd edition (VABS-2) parent/caregiver rating form. Scores obtained were
statistically correlated.

Results: Our results show that the three ELS measures were significantly correlated with multiple
measures from the VABS-2 when controlling for age.

Conclusion: Expressive language skills contribute to adaptive behavior in children, adolescents, and
young adults with DS regardless of age and some of these associations are not explained solely by
overall cognitive delays.
NARRATIVE LANGUAGE COMPETENCE IN CHILDREN AND ADOLESCENTS WITH
Down’s syndrome, fragile x syndrome and td children, Marie Moore Channell, et al., Frontiers
in Behavioral neuroscience, 2015.
Aim: to examine the narrative language abilities of children and adolescents with Down syndrome
(DS) in comparison to same-age peers with fragile X syndrome (FXS) and younger typically
developing (TD) children matched by nonverbal cognitive ability levels.

Methods: 23 individuals with DS, 22 with FXS and 23 TD. Inclusion criteris – Speech as primary
mode of communication, native English speaker, 3 word phrases.
Narrative task: Two wordless picture books were used to elicit narrative samples which were analysed
at two levels – Macrostructural (internal episodic structure, cohesion and coherence) and
Microstructural (Rate of use of specific word categories – adverbs, verb and conjunctions)

The transcripts were reviewed for grammatical content and MLU.

Results: Participants with DS showed lower rate of verb use than FXS and TD groups. This finding
suggests that individuals with DS have acquired the conceptual knowledge needed to express the key
story elements (at least to the level expected for their nonverbal cognitive ability), but that their
limited expressive syntactic abilities limit their ability to put that knowledge into words during the
course of telling a story.

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Hegde M N, Maul A C (2006) Language disorders in children, an evidence-based approach to

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Hegde M N (2006) Treatment Protocols for Language Disorders in Children; Vol II

Jr. Robert E. Owens (1991) Language Disorder: A Functional Approach to Assessment and
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Mecham J M (1976) Language disorders in children, A resource book for speech/Language

pathologists. Springler Link

Paul R & Norbury C F (2012). Language disorders from infancy through adolescence. Elsevier.

Reed V (2005) An introduction to children with Language disorder. Pearson

World Health Organization. (2019). International statistical classification of diseases and related
health problems (11th ed.). https://icd.who.int/
Del Hoyo Soriano, L., Villarreal, J. C., Sterling, A., Edgin, J., Berry-Kravis, E., Hamilton, D. R.,
Thurman, A. J., & Abbeduto, L. (2022). The association between expressive language skills and
adaptive behavior in individuals with Down syndrome. Scientific reports, 12(1), 20014.
https://doi.org/10.1038/s41598-022-24478-x

Channell, M. M., McDuffie, A. S., Bullard, L. M., & Abbeduto, L. (2015). Narrative language
competence in children and adolescents with Down syndrome. Frontiers in behavioral neuroscience,
9, 283. https://doi.org/10.3389/fnbeh.2015.00283