**2. Language Impairment (LI) and Specific Language Impairment (SLI)**

One of the most common worries in parents of young children concern their children's language and communication development and these are thus among the first aspects that parents as well as nurses at the Child Health Care (CHC) centers focus on in developmental screening procedures. Language delays are fairly common although there is a huge variation in typical early language development, in particular in expressive language, i.e. language production. Language impairment (LI) might be an early sign of a severe developmental disorder such as an intellectual disability and/or an autism spectrum disorder [36], although commonly it is only a question about problems of language development. Specific language impairment (SLI) is used as a diagnosis for markedly impaired expressive language when

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nonverbal intelligence has been tested and found to be within the normal range and if there are no apparent sensory or neurological dysfunctions. As [38] points out, SLI is not used if there is an autism-related disorder, but [38] also comment on the fact that "a notable minority of individuals with SLI move across subtypes throughout development" (p. 944). These authors made a review of possible links between different language impairments and autism spectrum disorders and ended up with the recommendation to "concentrate on those aspects of language impairment that predominate in each disorder rather than on those comparatively small areas of potential overlap" (p. 944). There are also several, but rare genetic disorders that cause both problems with language acquisition and autistic traits. Therefore, children with language problems should always be evaluated broadly as [13] pointed out in his formulation of Early Symptomatic Syndromes Eliciting Neurodevelopmental Clinical Examinations, ESSENCE. The speech and language therapist have a central role in the teamwork that scaffolds families with preschool children. However, in line with the ESSENCE thinking, the team must include disciplines representing child development as well as clinical psychologists, physio‐ therapists and social workers. The team must have access to several other consultant serviceschild neurologists, child psychiatrists and sometimes even adult psychiatrists. The latter should preferably have experience of developmental disorders in adults, as parents sometimes realize that they have or have had similar problems as their children have.

In line with the ESSENCE thinking, the child is often presented to the pediatrician as a child with a delayed gross motor function, especially delayed walking ability, often before two years of age. It is of great importance for the pediatrician not only to analyze and possibly exclude any neurological pathology behind this, but also to, in collaboration with the physiotherapist, instruct the parents how to stimulate the child´s development of gross motor function during everyday activities. It is also important to assess the level of the child´s development in all aspects including language production as well as comprehension, vision and hearing ability and social interaction. As the parents often at the first visit mainly are aware of the child's gross motor function and language production, the child must be observed and the parents must be asked to describe the level of other abilities. It is highly recommended to see the child regularly during the following years in order to, by watchful expectancy, observe development in all functions and, in case of delays in any ability, to consult other specialists.

Language and communication problems occur in different disorders and vary in symptoma‐ tology. Language is a complex skill covering perception as well as production of language and comprises both structural aspects such as phonology, morphology, syntax, and functional aspects, such as use of language in different social contexts, often referred to as pragmatic skill or ability of social communication. Another language skill reflects the meaning of words, the content of language, both in order to understand and interpret, and to retrieve words in narration, a skill which has many labels, i.e. semantic, lexical or vocabulary skill. For these reasons language problems often tend to coexist and be intertwined with other problems, and furthermore they tend to be persistent over time [34] although there is a large heterogeneity of causes as well as symptomatology.

Expressive language problems often elicit early concerns in parents. One reason is that expressive language is fairly easy for parents to notice and possibly take notes of. Another reason is that parents tend to compare with the development of siblings and peers. However, language skills, in particular language production, not only reflect how far the child has developed language skills, but also his/her interests and personality, which all are revealed by how much s/he is engaged in a topic and talks.

Language comprehension skills, often referred to as receptive language skills, however, are most often identified indirectly, for example by misunderstandings or by the child notably not paying attention. A consequence of this might be that language comprehension problems neither early nor easily are detected in small children. Another reason why language compre‐ hension problems tend to be ignored is that parents and those who know the child well intuitively facilitate for the child by sharing the same context with its referential objects, and thereby offer a redundancy of contextual information scaffolding the information given by words. Sometimes they almost "mind-read" the child and render the support the child needs in order to understand. This tendency to be "hidden" makes language comprehension problems particularly detrimental, especially since they are closely associated with generic learning skills with a long term negative effect on academic skills [6].

Another important aspect of language development is the ability to participate in social communication, often referred to as pragmatic skill. It is not easy for parents to neither describe nor evaluate the pragmatic skill of their children – the parents are themselves part of the communication and instinctively compensate the child in case of problems. For an early detection of pragmatic problems it is therefore necessary to ask teachers at preschool and school and use a questionnaire for example the Children's Communication Checklist [3], which focus on different aspects of social communication in a more neutral and descriptive way.
