Late Identification of Developmental Language Disorder in a Bilingual Child
A 5-year-old girl is referred by her teacher for 'not speaking properly'. She was born in Albania and moved to Italy at age 3; at home the family speaks Albanian, and she attends an Italian-language preschool. She produces short sentences in Italian (3–4 words), omits articles and verb endings, and has a limited Albanian vocabulary. Her teacher reports she rarely initiates conversation and often plays alone. Hearing screening at school was 'pass'. Her parents say her older brother 'was the same and grew out of it'. No standardized assessment in Albanian is available locally, and the family has no transport for repeated clinic visits.
1. What is the differential diagnosis, and what evidence would distinguish the possibilities?
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The main candidates are:
- Developmental language disorder (DLD) - persistent difficulties in both languages, not explained by exposure alone.
- Language difference due to sequential bilingual acquisition - normal for exposure, with errors typical of a second-language learner.
- Hearing loss - school screening is insensitive to mild/moderate or unilateral loss.
- Social-pragmatic/autism spectrum concerns - suggested by limited initiation and solitary play.
Key discriminators:
- Cross-linguistic evidence: if she shows the same grammatical weaknesses in Albanian (her stronger home language) as in Italian, this argues for DLD rather than a second-language effect.
- Family history: a sibling who 'grew out of it' is a risk factor for DLD, not reassurance.
- Formal audiology rather than a school screen.
- Pragmatic and play observation to assess social communication.
A bilingual child should not be labeled with a disorder on the basis of one language alone.
2. What assessment plan is feasible given the transport constraint, and how would you involve the family?
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A feasible plan:
- Bilingual language sampling at home and preschool: 10–15-minute play-based samples in each language, analyzed for mean length of utterance, verb morphology, and use of articles - compared against bilingual norms, not monolingual ones.
- Parent-report and teacher-report measures completed at home to avoid extra visits.
- One consolidated clinic visit combining audiology and a speech-language assessment, scheduled with the family's transport in mind.
- Interpreters or a bilingual co-worker for the Albanian sample, with the family's consent.
The family is engaged as co-assessors: explain that Albanian is an asset, ask them to record short samples at home, and give them simple strategies (naming, expanding utterances) to use while waiting for full assessment. This respects the family's language and reduces dropout.