Monique Touzin
Speech and Language Therapist
Hôpital Robert Debré
Hôpital Necker-Enfants Malades
Paris, France.

Language is a marvellous, magical and complex tool which is specific to human beings. Its acquisition by children continues to be surrounded by mystery which researchers are trying to solve. Language emerged when man was able to conceive and organize his activities, construct and classify mental representations of subjects, events and relationships (Damasio and Damasio, 1997). Language is a complex " savoir-faire " which most children develop in the absence of conscious effort or formal learning, and in all linguistic environments. They gradually master its different components and use it in a natural fashion. Children thus learn language " within the form and limits of genetic determination, while being influenced by specific indices provided by the language and the culture, which potentialize their instinctive tendency to acquire the art of talking " (Boysson-Bardies, 1999)

Language is immensely useful and valuable for all human activities and it is such an inherent part of daily life that it is difficult to imagine living without it. This is the reason why its failure to develop or its loss is always experienced as a dramatic event. Whether it involves a child who does not develop language, or develops it poorly or slowly, or an aphasic adult who suddenly loses all means of verbal communication, distress and grief are experienced by both the patient and the people in his (her) social environment.

The acquisition of language seems so natural and easy that we tend to forget the complexity of the processes involved. Unfortunately, it is a much more difficult process for some children, who then reveal all the suffering, distress and difficulties a human being is confronted with when he (she) is deprived of verbal communication.

Before communication becomes verbal, it uses gestures, cries, looks, signals. Communication is a vital need for the baby, for the child and the adult he will become. Language significantly determines the quality of communication which takes place between individuals, and it also mediates learning, creativity and pleasure. Language is therefore closely associated with areas of development such as symbolic play, peer relationships, and academic achievement (Baker and Cantwell, 1982).

The new-born baby is equipped with linguistic abilities when it comes into the world. It is genetically programmed to learn how to speak. This is well demonstrated by research on language perception in babies just a few weeks old. The baby learns the sounds of its maternal language throughout the first year of life, to the extent that, by the age of ten months, it can only discriminate the phonemes of this particular language. This is the way a child develops his(her) speech production system. In contrast to the limited linguistic productions of the first two months of life, the baby begins to play with sounds between five and seven months of age. It babbles recognizable syllables around the age of seven or eight months, the same syllables for all maternal languages, and is able to introduce syllable variations towards the end of its first year, producing vocalizations which already resemble phrases.

Before its first birthday, the baby is able to understand words, then to produce them. Initially, production is limited to single words, then language really develops around the age of 18 months. The child’s vocabulary explodes and syntax begins to emerge in its early form, as the juxtaposition of two words.

Between the end of the second year and the middle of the third year of life, language takes on a conversational, grammatically correct, form. This progression is striking and admired by everyone. In this respect, all children generally go through the same stages of development. For instance, as S. Pinter (1999) describes it so well, the three year old child is a " genius in grammar ": by that age, he has mastered most sentence constructions, follows rules rather than ignoring them, respects language universals, makes logical mistakes, and also avoids many different types of errors.

Language is part of all daily life activities, such as those of expressing emotions, loving, fighting, asking, transmitting, teaching, learning, creating. Complex language is universal because children really cannot help re-inventing it from one generation to the next.

Through language, the child is able to learn, first at home then in school. Knowledge is transmitted to the child, first through oral language then through written language. As a result, when a child does not acquire language, he is at risk of school failure and its long-term consequences of difficulties in social and occupational integration. When language disordered children are followed through their development, one notes an important increase in attentional and anxiety disorders, and indeed even the occurrence of behavioural disorders (Baker and Cantwell, 1987).

Human verbal communication does not involve a simple process of transfer of information: it involves a series of alternating behaviours produced by social animals which feel, calculate and anticipate. When we talk to other persons, our speech productions not only have an impact on them but they also reveal our own intentions. Each person has his (her) own way of communicating through unique postures and ways of speaking which reflect one’s identity and style of relating to others.

In addition, we know how to modulate our discourse according to the person we are speaking with, his(her) reactions, the content of his(her) message, and the context of the conversation. We can even " speak around " a subject, a way of talking we call politeness: " I was wondering whether you might consider meeting me " is a more tactful and socially acceptable way of talking to a person who is higher in rank than " I want to talk to you ". These distinctions are impossible unless the person has a good mastery of language and its nuances. These same verbal skills are required when one deliberately decides to violate tacit rules of conversation in order to create forms of communication such as irony, humour, metaphor, sarcasm, insult, counter answers, rhetoric, persuasion and poetry.

Beyond formal language deficits, language disordered children can also be impaired in their language usage, i.e., can display impaired pragmatic skills. This dimension concerns " the different characteristics of the use of language (psychological motivations and reactions of different speakers, social orientation and aim of the discourse, etc.), in contrast to the syntactic (formal properties of linguistic constructions) and semantic (relationships between linguistic units and the surrounding world) dimensions of language " (Dubois et al., 1973). The impairment of pragmatic skills can affect three levels of functioning: a global level of impairment where the person is generally unable to respond to social interactions and to engage in a conversation; a level of responsive but non assertive verbal behaviours, most likely due to a receptive or expressive disorder; and finally, the presence of a general conversational repertoire and of speech productions which are comparable to those of other children, but which are marked by a more restricted level of complexity because of specific language deficits (Fey and Leonard, 1983). Relationships between linguistic and pragmatic skills are the subject of much debate. Some authors hypothesize an association between pragmatic disorders and linguistic disorders (Hupet, 1996), while others report results which tend to indicate that these two types of skills are developmentally independent (de Weck, 1998).

The occurrence of lesions in adulthood is not the only way pathways underlying language can be damaged. In some children, language does not appear at the right time, and when these children begin to talk they are hindered by word articulation problems. Even when they improve with age, these children continue to display various types of grammatical errors which often persist until adulthood.

Numerous pathologies present symptom profiles which include impaired skills in language acquisition or language use: learning disabilities, genetic disorders, neurological disorders including aphasia, deafness, autism, mutism, or specific developmental language disorders. It is clearly important to assess the child’s linguistic characteristics, but it is also essential to integrate the different psychological, emotional, environmental and other dimensions which interact, each in its own way, with language development and verbal communication.

Once obvious non linguistic factors are ruled out, such as cognitive disorders in learning disabilities, perceptual deficits in hearing impairment, or social skill disturbances in autism, these children can be diagnosed as having a Specific Language Impairment (SLI).

Language integrates several different subsystems: " the phoneme subsystem, the lexeme subsystem, the morpho-syntactic subsystem, pragmatic regulations and discursive organization ". Each subsystem is relatively autonomous one from the other (Rondal, 1997).

In children, these different linguistic areas can be damaged to varying extents, affecting both expressive and receptive skills and resulting in impairment in the quality of communication.

On the expressive level, articulation and/or phonological disturbances impair the intelligibility of the child’s discourse, making it difficult for others to understand his verbal productions. Lexical limitations, which force the child to use many general purpose and imprecise words, generate a discourse which is not sufficiently informative. The child’s vocabulary can be restricted, unavailable or poorly ordered, thus hampering the fluidity and preciseness of language. Syntactic deficits prevent the child from expressing simple or complex thoughts, make his (her) discourse awkward because he (she) is unable to synthesize several ideas into one sentence, and deprive him of nuances. The person he speaks to tries to understand him(her), makes assumptions about what he means to express, and generates anger in the child when these assumptions are erroneous. Of course, all these attempts can greatly damage the quality of the interaction.

The impairment may also involve language comprehension, which may have a negative impact on interpersonal interactions as well. Different levels of distortion are also possible in this case. Some subjects are unable to identify meaningful words within a sequence of sounds, others cannot master syntactic forms.

Some disorders involve the use of language in conversation by the child (pragmatic skills). In this case, the child does not know how to conduct a conversation, how to take turns, produce verbalizations which are appropriate to the social context, initiate or change a topic of conversation, answer different types of questions in an appropriate fashion (de Weck, 1998).

The purpose of language evaluation is not only to identify those dimensions involved in the formal aspects of language acquisition, but also to assess, in situations of daily communication and learning, the impairment which results from the deficits identified. The evaluation of language skills should not be restricted to a list of symptoms or to measures of severity; it should also assess these deficits within the broader context of the child’s whole functioning and of his (her) existing communication skills. A precise evaluation of the child’s disorders will help us understand his (her) difficulties, build appropriate remedial strategies and select the best treatment modalities.

The aim of speech and language therapy is to help the child discover or re-discover the wish to communicate and the pleasure it gives, beyond the difficulties he (she) experiences in manipulating language tools. For this purpose, the speech and language therapist can use non verbal material as props, such as pictograms, gestures, mime or facial mimicking...These visual props can be maintained for a while, until oral language skills are consolidated.

In this manner, the therapist will help the child improve his (her) language skills, develop learning skills in order to reach a better understanding of the world he lives in, and build or re-build instruments of communication geared to improving social integration skills.

The remediation of deficits, the development of strategies, the reinforcement of existing skills, these are all challenges the speech and language therapist must face, to ensure the child’s full development within the family as well as optimal school and social integration. When evaluating pragmatic skills, therapists should always keep in mind that it is not enough to provide the child with a repertoire of tools; they must also help him develop self-confidence and appropriate ways of using these tools.

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