86 Mixed Receptive-Expressive Language Disorder (315.32)

DSM-IV-TR criteria

• A. The scores are obtained from a battery of standardized, individually administered measures of both receptive and expressive language development which are substantially below those obtained from standardized measures of nonverbal intellectual capacity. Symptoms include those for Expressive Language Disorder as well as difficulty understanding words, sentences, or specific types of words, such as spatial terms.
• B. The difficulties with receptive and expressive language significantly interfere with academic or occupational achievement, or with social communication.
• C. Criteria are not met for a Pervasive Developmental Disorder.
• D. If Mental Retardation then a speech-motor, sensory deficit, or environmental deprivation is present; the language difficulties are in excess of those usually associated with these problems.

Coding note: If a speech-motor or sensory deficit or a neurological condition is present, code the condition on Axis III.

Associated features

• The essential diagnostic feature of Mixed Receptive-Expressive Language Disorder is a disability found in the development of both the receptive and expressive language as demonstrated by standardized testing that is individually administered and measures both receptive and expressive language development. The scores are significantly below the standardized measures of the nonverbal intellectual capacity as in Criterion A. When unable to or inappropriate to do standardize testing, the diagnosis can be based on a methodical practical assessment of the person’s language ability.
• The language difficulties in communication may involve verbal and sign language. The difficulties with the communication hinder the academic or occupational achievement and social communication in accordance with Criterion B, and the symptoms do not meet the criteria for Pervasive Developmental Disorder as with Criterion C. Criterion D gives one more feature which is that if Mental Retardation, a speech-motor or sensory deficit, or environmental deficiency are present, the language difficulties are in excess. If a speech-motor or sensory deficit or a neurological condition is present, the disorder is coded on Axis III.
• An individual diagnosed with Mixed Receptive-Expressive Language Disorder has the same difficulties as someone diagnosed with Expressive Language Disorder, but also has difficulties with understanding words, sentences, or specific types of words, which is receptive language development. There are milder cases where there are only difficulties with understanding particular types of words like spatial terms or with statements such as complex sentences. The more severe cases may have multiple disabilities.
• These disabilities include an inability to understand basic vocabulary and/or simple sentences, along with a deficiency in the discrimination of sounds, association of sounds and symbols, recollection, storage, and sequencing. The development of expressive language in children depends on the acquisition of receptive language skills, therefore it is hardly ever seen that a child will be diagnosed with a pure receptive language disorder.
• The linguistic features of Mixed Receptive-Expressive Language Disorder in the production impairment are quite similar to Expressive Language Disorder as previously stated. It is comprehension that distinguishes Mixed Receptive-Expressive Language Disorder from Expressive Language Disorder. The comprehensive distinguishing feature varies depending on the severity of the disorder and the age of the child. Difficulties with language comprehension are not as easily recognizable as language production difficulties. They may only appear under formal observation. The child will show poor or nonexistent conversational skills, may seem to follow directions incorrectly or not at all and give inappropriate answers to questions asked of them.

Child vs. adult presentation

Acquired Mixed Receptive-Expressive Language Disorder is seen at any age. Developmental Mixed Receptive-Expressive Language Disorder is seen in children with a normal onset at or around age 4. Severe forms of Mixed Receptive-Expressive Language Disorder can be detected by age 2. The milder forms may not be detected until the child reaches school where comprehension problems become more apparent.

Gender and cultural differences in presentation

The developmental type is more prevalent in males than in females. Prevalence estimates vary with age. When doing the assessment of the disorder, the cultural and language context must be taken into account. This is especially important in bilingual environments. The standardized measurements of the language development and nonverbal intellectual capacity have to be relevant for cultural and linguistic groups.

Epidemiology

• Other disorders that are associated with Mixed Receptive-Expressive Language Disorder include Phonological Disorder, Learning Disorders, and deficits in the perception of speech and impairment of memory. In addition, Attention-Deficit/Hyperactivity Disorder, Developmental Coordination Disorder, and Enuresis are sometimes present in the developmental type. Mixed Receptive-Expressive Language Disorder is occasionally accompanied by EEG abnormalities, and other neurological signs.
• Acquired Mixed Receptive-Expressive Language Disorder can happen at any age. A form of acquired Mixed Receptive-Expressive Language Disorder has an onset of 3-9 years of age. It is accompanied by seizures and referred to as Landau-Kleffner syndrome.
  The prognosis of acquired Mixed Receptive-Expressive Language Disorder depends on the severity of the brain damage and the location of the damage. It also depends on the extent of the language development when the disorder is acquired.
• The developmental Mixed Receptive-Expressive Language Disorder has its onset as previously stated beginning at or around the age of four. There is an estimate of the developmental type of Mixed Receptive-Expressive Language Disorder that occurs in up to 5% of preschool children and 3% of school-age children. It is essentially less common than Expressive Language Disorder, Landau-Kleffner syndrome and the other forms of acquired Mixed Receptive-Expressive Language Disorder.
• Severe forms of the developmental Mixed Receptive-Expressive Language Disorder have their onset by 2 years of age. The milder forms may not be detected until the child reaches elementary school. A child who has Mixed Receptive-Expressive Language Disorder will eventually acquire normal language skills, but the prognosis for those with Expressive Language Disorder is worse.
• Developmental Mixed Receptive-Expressive Language Disorder is more common with first-degree biological relatives with the disorder than the general population. The acquired Mixed Receptive-Expressive Language Disorder has no evidence of familial ties.

Etiology

• Mixed Receptive-Expressive Language Disorder can either be acquired or developed. Developmental Mixed Receptive-Expressive Language Disorder does not have a known cause. Research is being conducted to
  determine if the cause is biological, environmental, or both. Malnutrition during pregnancy probably plays a major role in developmental Mixed Receptive-Expressive Language Disorder.
• Acquired Mixed Receptive-Expressive Language Disorder is generally caused by an injury to the brain. The injury to the brain can be either direct trauma such as head injuries or indirect trauma such as strokes, or seizures. Acquired Mixed Receptive-Expressive Language Disorder is commonly misdiagnosed as a Developmental Disorder. Developmental Mixed Receptive-Expressive Language Disorder and other receptive language disorders start showing symptoms beginning around the age of four.
• The specific symptoms of acquired Mixed Receptive-Expressive Language Disorder depend on which area of the brain received damage, and also on how severe the damage is.
• The symptoms for developmental Mixed Receptive-Expressive Language Disorder are extremely similar to the symptoms of Expressive Language Disorder. The symptoms vary considerably from child to child. Generally speaking, Mixed Receptive-Expressive Language Disorder is characterized by a difficulty with spoken communication. The child can pronounce the words, unlike Phonological Disorders, but has problems with coherent syntax, the usage of proper grammar, and word recollection.
• A child who is diagnosed with Mixed Receptive-Expressive Language Disorder has trouble communicating his or her thoughts, needs, and what he or she wants at the same level or same complexity as other children the child’s age. The child generally has a smaller vocabulary as well.

Empirically supported treatments

• There can be complete or nearly complete clinical improvement in language abilities. There are some instances that may have incomplete recovery or progressive insufficiency. Mixed Receptive-Expressive Language should be treated as soon as you reach a diagnosis. Clinical improvement is more likely with early intervention.
• Treatment involves anyone who interacts regularly with the child diagnosed with the disorder. One-on-one treatment regularly scheduled, that focuses on specific language abilities can be effective. Pair the one-on-one treatment with a more general approach with family and caregivers is more effective.
• Teaching the child specific communication skills for interaction with his/her peers is extremely important. This could avoid problems later in life like social isolation, depression, and/or behavioral problems. Teaching the child reading skills will benefit the child to avoid serious long-term academic problems.

Christian age four diagnosed with Mixed receptive-Expressive language disorder. See video: