It is important for physicians who work with children to be familiar with the linguistic development of school age youngsters. Often the focus of training is the language development of infants, toddlers, and preschoolers: when children should babble, use individual words, put two words together, and follow simple directions. However, a great deal of language development occurs during the elementary school years; in fact, it has been said that the critical period for linguistic acquisition extends through adolescence. ' This article describes the developing linguistic abilities of 6- to 12-year-old children and discusses dysfunctions of these skills with their educational and scK ial impacts.
Language abilities are the most important skills a child brings to the educational setting. Through language a child receives and transmits ideas, feelings, and information. Language also plays a vital role in social interactions, storing information, and thinking. Language development beyond the age of 6 is particularly important because it marks the transition from a loosely structured home environment to the rigorously structured classroom.2 Information goes from being transmitted in a one-to-one setting with many cues and expectations of home to the group environment of the unpredictable classroom.
To assist in describing the elementary age child's acquisition of linguistic skills, those skills will be grouped into expressive (the ability to retrieve and express thoughts) and receptive skills (the ability to receive and interpret language). Developmental focus will be on three periods during the elementary years: the 6-year-old period (a child's abilities upon entering school), the 7- to 9-year-old period (abilities of the early elementary school age child), and the 10- to 12year-old period (the later elementary and early middle school child). Although this is to some extent an artificial classification, it generally represents natural transitions during the evolution of children's language skills.
ENTRY INTO SCHOOL (6 YEAR OLDS)
Children enter elementary school with the phonic and morphologic abilities acquired during the toddler and preschool years. Phonic skills involve the appreciation of individual sound units and sound symbol sequences as well as the ability to discriminate between sounds; morphologic abilities involve the knowledge of rules for combining units of meanings to convey specific ideas. These skills allow children to understand language and to generate thoughts and desires. Such skills are not taught and are developed informally during the first six years of life.
Receptive Language Skills
Six-year-old children bring a remarkably well developed vocabulary to the classroom. In fact, focus during the school years is more on the appreciation and flexible understanding of individual words in various contexts than on increasing the number of vocabulary words. However, words involving motion (eg, before-after, ahead-behind, come-go, or bring-take) give the child difficulty and may prove elusive until 8 years of age.4,5 Additionally, 6 year olds have problems with factitive verbs such as know, think, or believe.6
Syntactic abilities clearly distinguish 6 year olds from older children. Six year olds have difficulty understanding relative clauses such as "a turkey that the gorilla patted pushed the pig·"7 Even those who understand the individual words "before" and "after" have difficulty processing them when they are included in sentences. Often these children overrely on canonical order strategies. That is, they assume in nounverb-noun sentences the first noun is the acror and the second noun is the occupant of the action. "A cat ran after the mouse" illustrates this order whereas "the cat was chased by the dog" reverses it. Children often will understand such sentences because the context of the situation will override reliance on order; but when this does not occur (such as in "the boy was hit by his sister" where it is equally likely that the boy or the girl could be doing the hitting), confusion may result.
Also, reliance on the "minimal distance principle" may prove hazardous for these children. The principle that the noun closest to the infinitive is the subject of the infinitive can prove helpful in sentences such as "Suzie told Beth to leave" but when verbs such as "promise" are used ("Suzie promised Beth to buy the drink"), the 6 year old may assume Beth, not Suzie, was to do the buying.
Given these limitations, 6 year olds generally should be able to interpret and correctly answer complex sentence and question combinations (eg, "A boy saw the man who was carrying a red ball. Who was carrying a red ball?" "The lady saw the man who was wearing a green hat. Who was wearing a green hat?").
Another skill evolving during the school years is the ability to attend to auditory stimuli. The limitations of their semantic and syntactic abilities make it difficult for 6 year olds to attend to and follow complicated directions. Because the kindergarten environment generally does not place significant stress on these skills, most children do not experience difficulties. In general, however, these children should be able to follow such directions as "put the pencil behind your knees," "touch the bottom of your chair near the back," and "here are a penny and a pencil. First give me the penny then give me the pencil. "
Expressive Language Skills
Word usage grows considerably during the school years. For example, Brown8 listened to spontaneous speech samples of children and observed that their acquisition of specific morphemes progressed fairly regularly through the early elementary years. Production words (eg, prepositions, regular plurals, irregular past tenses, and articles) followed predictable sequences.
Generally, the young elementary age child is expected to carry on a regular conversation and to name common items without undue difficulty. For example, children should be able to name common objects such as ball, picture, hammer, or umbrella without undue hesitation or circumlocution (describing rather than naming the item).
The ability to find and retrieve words quickly is an evolving developmental skill. Throughout the school years there is an increasing demand on children to produce what they know in a specific period (eg, when called on in class and timed quizzes). Most 6-year-old children should be able to retrieve the names of five or more animals or foods within 30 seconds.
Narrarive skill is another emerging trait that can prove elusive for 6 year olds. An experiment by Krauss and Gluksberg9 illustrates this point well. Their experiment involved separating two children by an opaque screen and asking one child to place six blocks with novel designs on a peg. These blocks were then described so that the other child could do the same. In general, 5 to 6 year olds could not communicate this information despite multiple trials. In fact, it was not until 8 years of age that this task could be accomplished, and then only after several trials.
Finally, metalinguistic skills (the ability to make conscious judgments about language and to use language to think about language) are just emerging in the 6 year old. 10 Not until the age of 6 or older are children able to understand metaphors or to tell jokes or deliberate lies.
EARLY ELEMENTARY SCHOOL (7 TO 9 YEAR OLDS)
The years 7 to 9 are generally a transition time: children are progressing from a basic understanding of syntax hampered by the minimal distance principle and difficulty with embedded clauses to a stage of mental linguistic growth when metaphors and similies play an increasingly important role.11 Also, during this stage emphasis is on output and expressive abilities.
Receptive Language Skills
By 8 and 9 years old, verbs indicating motion are mastered. Children are improving their ability to understand conjunctions such as because, if, although, and unless. Generally by 8 years of age children finally understand verbs such as promise4; verbs such as go, take, come, and bring may prove elusive until 9.12
Significant syntactic growth has also occurred. Children have achieved the ability to ignore canonical order strategies and should be able to understand sentences that violate this rule. For example, sentencequestion combinations such as "The boy promised the girl who was there to walk the dog. Who walked the dog?" and "The woman asked the man who was watching which hat to wear. Who wore the hat?" should be mastered by children from 8 to 9 years of age.
The second or third grader has acquired the ability to use pronouns. For example, the kindergartner lacks the awareness that in the sentence "Steven knew he would climb a tree" that "he" could be referring to a person other than Steven. The older elementary age child can make the correct inference. Therefore, these children are less likely to engage in literal interpretations of sentences.
Children's ability to attend to auditory detail also improves during this period. This improvement is fortunate because the classroom is evoling from a manipulative visual environment with hands-on teaching to classrooms where much of the learning is in lecture format. By 8 years of age children should have the ability to attend to and follow complicated directions such as "Touch the middle square with your pencil and then with your finger"; "Draw a line from the dot that is alone to the top of the small square"; "Make a square in the small circle and make a circle in a small square" (Figure).
A child's metalinguistic skills evolve during these years. The ability to think about language is expanding. Telling jokes and appreciating metaphors has begun to emerge, as is the ability to tell stories clearly. Unfortunately, storytelling often takes the form of lying.
Figure. Stimulus for the Verbal Instructions subtest of the Pediatric Early Education Examination and the Pediatric Examination of Educational Readiness at Middle Childhood.
Expressive Language Abilities
Children's expressive abilities are improving during these years to match the increasing switch from assimilation to production that occurs between first and fourth grade. Children's ability to use the words they know improves their narrative skills significantly. A child can now, by improved storytelling and summarization skills, explain tasks so another child can reproduce them.
LATE ELEMENTARY SCHOOL (10 TO 12 YEAR OLDS)
Receptive Language Skills
By late elementary school children have consolidated much of their semantic skills. l i Factitive verbs (eg, know, think, and believe) are now basic to their vocabulary, and they understand that these verbs presuppose the truth of any complementary clause even if the factitive verb is negated in the main clause. For example, if one says "Jim knows that Bill is an athlete" or "Jim doesn't know that Bill is an athlete," both sentences presuppose that Bill is an athlete. By 10 year old this type of grammatical understanding should be part of a child's semantic skills.
Intonations and the subtleties of reflection are usually developed by 10 years of age. For example, the meaning of the sentence "Give the book to John" can be changed by placing the stress on each word. After 10 the ability to utilize inflection is generally available, although some evidence indicates that particular aspects of intonations that convey meaning are not totally comprehended until many years later. ,4
The most important linguistic change at this age is the ability to use language as an object with which one may play or put to work in figurative ways. This metalinguistic awareness allows an older child to appreciate jokes, understand metaphors, and recognize the ambiguity of language.
These children also have developed sophisticated narrative skills that enable them to tell stories and clearly express their thoughts. The knowledge of general and specific morphologic rules has become well differentiated and the late elementary school child should be adept at manipulating specific word endings, prefixes, and suffixes. Word finding abilities along with quick retrieval skills are emerging to meet requirements for long reports and quick answers on timed tests.
Growth in language skills has increased expectations for 10- to 12-year-old children. They should understand and answer questions involving fairly sophisticated concepts. For example, this sentencequestion combination involving a complex sentence with a conditional conjunction should be answered correctly: "Ricky won't go to the party unless Ann goes. Will Ricky stay home?" Also, the use of a factitive verb in the negative tense should not be elusive: "They could not believe that Joe was telling the truth. Was Joe lying?"
The child's ability to attend to and follow directions involving increasing detail should be more sophisticated. Referring to the Figure, a 10 to 12 year old should be able to follow directions involving condensed syntax such as "Draw a line from the dot that is alone to the bottom of the square that is in the middle" or "Make a circle in the big square and then make a square in the middle one." Also, directions involving active working memory (eg, "Before you make four x's above the middle square, draw a line connecting two circles" or "Put three dots above the thick line after you have made a square and circle underneath it") should be mastered.
Expressive Language Skills
Children of these ages should be able to formulate grammatically correct sentences when provided with specific words such as walk, road, and until. (Don't walk on the road until the light is green) or without, road, dark, and rocky (Don't walk on the dark, rocky road without a flashlight). Retrieval skills should be such that a child can readily name animals or liquids on request and can quickly answer questions such as "Part of a book? Something you catch? Opposite of sweet?" Finally, word finding skills should make it easy for a child to look at a picture of a common living room and label specific items such as shade, socket, plug, and curtain.
COMMON LINGUISTIC DISORDERS
Common linguistic dysfunctions that adversely affect a school age child are addressed below. In general, a developmental sequence is followed so that problems affecting children in the early grades are discussed before disorders that are often not manifested until later elementary school. Unfortunately, the scope of this article does not allow for the discussion of the diagnosis and treatment of these difficulties. An excellent review can be found, however, in a recently published developmental textbook.15
Poor Phonetic and Chronologic Skills
Children who have difficulty appreciating individual sound units and sound sequence often experience difficulty in kindergarten or first grade when phonics are introduced. Often these children develop sight vocabularies (the ability to recognize a word from memory) but cannot sound out unexperienced words. When looking at a new word such as "cook" a child often will make a visual guess such as "cat" based on a general visual configuration. Fortunately, if this difficulty is isolated, these children, with appropriate remedial help, can learn the necessary skills to become good readers.
Semantic and Morphologic Disorders
Children with semantic and morphologic difficulties usually will start having problems in the early elementary years after rudimentary reading skills have been developed. Children diagnosed as learning disabled have been shown to know fewer words and have poorer symbolization and conceptualization skills than average children. These students become confused with words that have multiple meanings and have difficulty keeping up with the rapid vocabulary growth acquired during elementary school. Wiig, Semel, and Crouse16 demonstrated that children with morphologic problems had difficulty understanding tenses, plurals, and possessive forms, particularly in early elementary school
Children who have poor sentence comprehension and difficulty interpreting word order and grammar generally emerge as problem learners later in elementary school when the demand increases for understanding sophisticated explanations and directions. These children often rely heavily on semantic or contextual cues that may mislead interpretation of material- Difficulty in these areas often are the most troublesome in the long run because the requirements for understanding sophisticated grammatical context continually increase through school.17
Poor Metalinguistic Monitoring
Children without a strong conscious sense of language often start to flounder near the end of elementary school, when creative production demands are increasing. These children are deficient in their ability to use figurative language and analogies. i8 Poetry and prose often are not interpreted well because these children cannot reread their work and determine if it is grammatically incorrect or does not make sense. If their problems are isolated, however, these children can maintain themselves through elementary school and generally do not have difficulties until the later years.
Poor Auditory Attention
Difficulties attending to auditory material affect the child throughout the elementary years, although they are more hazardous in the later years when the visual environment of kindergarten and first grade transfers to the more verbal environment of fourth grade where long classroom discussions and directions prevail. These children often become confused because of an inability to follow directions. Thus, they are often considered unmotivated or la2y because they do not complete assignments or turn in homework due to confusion over instructions. A recent study, in fact, has shown that the inability to process and follow auditory directions was most closely associated with academic and social dysfunction.19
Word Finding Disorders
Children with word finding difficulties experience problems throughout school. Such problems are clearly associated with reading difficulties20 and can result in social defensiveness from an inability to keep up with social banter. This often results in being overwhelmed socially and can lead to social passivity and even isolation.
Quick retrieval difficulties, a type of word finding problem, also can prove disarming in the classroom. Increasingly, children must be able to answer questions quickly and perform well on timed tests. If a child has difficulty when asked to retrieve information quickly, test performance may become problematic.
Obviously, it is unlikely that any child will have only one of the specific language difficulties mentioned above. In fact, most children have clusters of such problems which compound to make learning difficult. The approach of this article has been to separate such problems in an attempt to make linguistic functioning clearer to practicing physicians who have little time to leam its complexities.
This article has shown that the elementary school years are vital for the growth of linguistic skills. During this period children go from a relatively rudimentary understanding of syntax and grammar to a very sophisticated appreciation of the complexities of language. Syntactic skills also are increasing during these years, particularly the ability to understand factitive verbs and complicated prepositions and conjunctions. Additionally, the child is developing a greater awareness of what language is and how to manipulate and use it. This allows the youngster greater flexibility in dealing with metaphors, poetry, and linguistic interpretation. A child's expressive skills improve during the elementary years; both the ability to narrate events and to provide appropriate information is increasing dramatically. The child progresses from learning to write sentences to producing long term papers and sophisticated reports. Also, it has been shown that children who have problems in these areas are at risk for academic failure and social isolation.
Pediatricians play a significant role in identifying children with such problems. Often children are not discovered by teachers who are overwhelmed by large classes or encumbered with a complicated curriculum. Fortunately, physicians come in contact with children regularly and, by asking the right questions and inquiring about school progress, they can often determine if a child needs further assessment. In addition, instruments have been specifically designed to enable physicians to assess the age-appropriateness of a child's linguistic skills.21"23 By using specific subtests physicians can quickly determine whether a child's receptive, expressive, or syntactical skills are intact.
Following such a protocol is important. Children with language skill deficit are at great risk for humiliation in the highly linguistic school environment. Bypass strategies and remedial techniques exist that can significantly improve functioning. More important, these children often have other skills and assets that are not tapped at school. By directing the child to areas of other strengths such as sports, arts, or mechanical skills, a child's self-esteem and confidence can be protected during the school years. In the context of providing good medical care, this may be the most important contribution the physician can make to a child's overall health and well-being.
Examples of age-appropriate skills were, in general, taken from subtests of the Pediatric Exam of Educational Readiness, the Pediatric Early Educational Examination, and the Pediatric Examination of Educational Readiness at Middle Childhood.
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