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Nelson HD, Nygren P, Walker M, et al. Screening for Speech and Language Delay in Preschool Children [Internet]. Rockville (MD): Agency for Healthcare Research and Quality (US); 2006 Feb. (Evidence Syntheses, No. 41.)

  • This publication is provided for historical reference only and the information may be out of date.

This publication is provided for historical reference only and the information may be out of date.

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Screening for Speech and Language Delay in Preschool Children [Internet].

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3Results

Key Question 1. Does Screening for Speech and Language Delay Result in Improved Speech and Language as well as Improved Other Non-speech and Language Outcomes?

No studies addressed this question.

Key Question 2. Do Screening Evaluations in the Primary Care Setting Accurately Identify Children for Diagnostic Evaluation and Interventions?

2a. Does Identification of Risk Factors Improve Screening?

A total of 246 abstracts about risk factors for speech and language delay were identified from literature searches, and 78 full text papers were reviewed. Nine studies conducted in English speaking populations,3846 and 7 studies from non-English speaking populations4753 met inclusion criteria (Table 3; Appendix 6).

Table 3. Summary of Studies of Risk Factors.

Table 3

Summary of Studies of Risk Factors.

English-language studies included case control,39, 4143, 45 cross sectional,38, 40, 44 and prospective cohort46 designs. Sample sizes ranged from 2438 to 1,10245 subjects. Most studies evaluated risk for language delay with or without speech delay, and one restricted the evaluation to expressive language only.46 Family history was the most consistent significantly associated risk factor in 5 of 7 studies that examined it.39, 41, 4345 Family history was defined as family members who were late talking or had language disorders, speech problems, or learning problems. Male sex was a significant factor in all 3 of the studies examining it.39, 41, 44 Three39, 43, 45 of 5 studies reported an association between lower maternal education level and language delay, while 34345 of 4 studies evaluating paternal education level reported a similar relationship. Other associated risk factors reported less consistently included childhood illnesses,38, 42 born late in the family birth order,44 family size,41 older parents41 or younger mother45 at birth, and low socioeconomic status or minority race.42 One study evaluating history of asthma found no association with speech and language delay.41

The 7 studies assessing risk in non-English speaking populations include case control,49 cross sectional,47 prospective cohort,5053 and concurrent comparison48 designs ranging from 7248 to 8,37053 subjects. Studies evaluated several types of delay including vocabulary,48 speech,47 stuttering,49 language,5053 and learning.5153 Significant associations were reported in the 2 studies evaluating family history,47, 50 and one of 2 studies evaluating male sex.53 Three of 4 non-English language studies, including a cohort of more than 8,000 children in Finland,53 reported significant associations with perinatal risk factors such as prematurity,52, 53 birth difficulties,47 low birth weight,53 and sucking habits.47 An association with perinatal risk factors was not found in the one English language study that examined low birth weight.45 Other associated risk factors reported less consistently include parental education level,51, 52 and family factors such as size and overcrowding.52, 53 These studies did not find associations with mother's stuttering or speaking style or rate,49 mother's age,53 and child temperament.48

Key Questions 2b and 2c. What Are Screening Techniques and How Do They Differ by Age? What Is the Accuracy of Screening Techniques and How Does It Differ by Age?

A total of 44 papers reporting performance characteristics of 51 screening evaluations met inclusion criteria. Techniques taking 30 minutes or less to complete that could be administered in a primary care setting were considered to have potential for screening purposes, although many instruments were not designed specifically for this use. Studies utilized a variety of standardized and nonstandardized instruments and compared them with several different reference standards. No gold standard was acknowledged or used across studies. Instruments are described in Appendix 7. Studies were grouped by age categories according to the youngest ages included, although many studies included children in overlapping categories. Studies provided limited demographic details of subjects, and most included predominantly Caucasian children with similar proportions of boys and girls. Studies are summarized in Table 4 (up to 2 years old), Table 5 (ages 2 to 3 years), and Table 6 (ages 3 to 5 years). Quality scores are described in Appendix 8.

Table 4. Screening Instruments for Children Up To 2 Years Old.

Table 4

Screening Instruments for Children Up To 2 Years Old.

Table 5. Screening Instruments for Children 2 to 3 Years Old.

Table 5

Screening Instruments for Children 2 to 3 Years Old.

Table 6. Screening Instruments for Children 3 to 5 Years.

Table 6

Screening Instruments for Children 3 to 5 Years.

Ages 0 to 2 years. Twenty-one studies described performance characteristics of 25 evaluations for children up to 2 years old.12, 29, 5472 Eleven studies from 10 publications utilized instruments taking 10 minutes or less to administer, including the Early Language Milestone Scale,29, 63 Parent Evaluation of Developmental Status,67 Denver Developmental Screening Test II (language component),68 Pediatric Language Acquisition Screening Tool for Early Referral,60 Clinical Linguistic and Auditory Milestone Scale,65 Language Development Survey,54, 58, 69 and the Bayley Infant Neurodevelopmental Screener.56 Of these, 6 studies tested expressive and/or receptive language,29, 56, 60, 63, 67, 68 3 expressive vocabulary,54, 58, 69 one articulation,73 and one syntax and pragmatics.65 Testing was conducted in general health clinics, specialty clinics, day care centers, schools, and homes by pediatricians, speech and language specialists, psychologists, medical or graduate students, parents, and research assistants. Study sizes ranged from 4863 to 42258 subjects. One study enrolled predominantly African American children.60

For the 10 fair and good-quality studies providing data to determine sensitivity and specificity of evaluating children up to 2 years old with instruments administered in 10 minutes or less sensitivity ranged from 22% to 97% and specificity from 66% to 97% (Figure 3ab).29, 54, 56, 58, 60, 65, 6769 Four studies reported sensitivity and specificity of 80% or better: a fair-quality study using the Early Language Milestone Scale,29 2 studies, rated fair to good69 and fair,54 using the Language Development Survey, and one fair-quality study using the Clinical Linguistic and Auditory Milestone Scale.65 The study of the Clinical Linguistic and Auditory Milestone Scale also determined sensitivity and specificity by age, and reported higher sensitivity/specificity at age 14 to 24 months (83%/93%) than 25 to 36 months (68%/89%) for receptive function, but lower sensitivity/specificity at age 14 to 24 months (50%/91%) than 25 to 36 months (88%/98%) for expressive function.65 A study testing expressive vocabulary using the Language Development Survey indicated higher sensitivity/specificity at age 2 years (83%/97%) than at age 3 years (67%/93%).54

Figure 3A. Sensitivity and Specificity of Instruments for Ages up to 2 years.

Figure

Figure 3A. Sensitivity and Specificity of Instruments for Ages up to 2 years. Studies rated fair to good with instruments taking 10 minutes or less time to administer

Figure 3B. References for Figure 3A.

Figure

Figure 3B. References for Figure 3A.

Ages 2 to 3 years. Twelve studies described performance characteristics of 14 evaluations for children ages 2 to 3 years.11, 7484 Ten studies in 9 publications utilized instruments taking 10 minutes or less to administer, including the Parent Language Checklist,11 Structured Screening Test,75 Levett-Muir Language Screening Test,81 Fluharty Preschool Speech and Language Screening Test,76, 83 Screening Kit of Language Development,77 Hackney Early Language Screening Test,79, 80 and Early Language Milestone Scale.84 All studies tested expressive and/or receptive language,11, 7577, 7981, 83, 84 3 articulation,76, 83 and one syntax and phonology.81 Testing was conducted in general health clinics, specialty clinics, preschools, and homes by pediatricians, speech and language specialists, teachers, parents, and health visitors. Study sizes ranged from 2579 to 2,59011 subjects. One study included subjects predominantly from rural areas.83

For the 8 fair and good quality studies providing data to determine sensitivity and specificity of evaluating children ages 2 to 3 years with instruments administered in 10 minutes or less, sensitivity ranged from 17% to 100% and specificity from 45% to 100% (Figure 4ab). Two studies reported sensitivity and specificity of 80% or better: one study rated fair that used the Levett-Muir Language Screening Test,81 and one rated fair that used the Screening Kit of Language Development.77 The study of the Screening Kit of Language Development reported comparable sensitivity/specificity at ages 30 to 36 months (100%/98%), 37 to 42 months (100%/91%), and 43 to 48 months (100%/93%).77

Figure 4A. Sensitivity and Specificity of Instruments for Ages 2 to 3 Years.

Figure

Figure 4A. Sensitivity and Specificity of Instruments for Ages 2 to 3 Years. Studies rated fair to good with instruments taking 10 minutes or less time to administer

Figure 4B. References for Figure 4A.

Figure

Figure 4B. References for Figure 4A.

Ages 3 to 5 years. Eleven studies described performance characteristics of 12 evaluations for children ages 3 to 5 years.73, 76, 8593 Three studies utilized instruments taking 10 minutes or less to administer, including the Fluharty Preschool Speech and Language Screening Test,73 Test for Examining Expressive Morphology,88 and the Sentence Repetition Screening Test.93 Of these, 2 studies tested expressive and receptive language and articulation,73, 93 and one expressive vocabulary and syntax.88 Testing was conducted in general clinics, specialty clinics, and preschools by nurses, speech and language specialists, and teachers. Study sizes ranged from 4088 to 18273 subjects.

For the 3 fair quality studies providing data to determine sensitivity and specificity of evaluating children ages 3 to 5 years with instruments administered in 10 minutes or less (including the study of the Screening Kit of Language Development described in the previous section77), sensitivity ranged from 57% to 100% and specificity from 80% to 95% (Figure 5ab).73, 77, 93

Figure 5A. Sensitivity and Specificity of Instruments for Ages 3 to 5 years.

Figure

Figure 5A. Sensitivity and Specificity of Instruments for Ages 3 to 5 years. Studies rated fair to good with instruments taking 10 minutes or less time to administer

Figure 5B. References for Figure 5A.

Figure

Figure 5B. References for Figure 5A.

Systematic review. A Cochrane systematic review of 45 studies, including most of the studies cited above, summarized the sensitivity and specificity of instruments taking 30 minutes or less to administer.9 Sensitivity of instruments for normally developing children ranged from 17% to 100%, and for children from clinical settings from 30% to 100%. Specificity ranged from 43% to 100%, and 14% to 100% respectively. Studies considered to be of higher quality tended to have higher specificity than sensitivity (+=4.41, p<0.001), however, high false-positive and false-negative rates were often reported.9

2d. What Are the Optimal Ages and Frequency for Screening?

No studies addressed this question.

Key Question 3. What Are the Adverse Effects of Screening?

No studies addressed this question. Potential adverse effects include false positive and false negative results. False positive results can erroneously label children with normal speech and language as impaired, potentially leading to anxiety for children and families and further testing and interventions. False negative results would miss identifying children with impairment, potentially leading to progressive speech and language delay and other long-term effects including communication, social, and academic problems. In addition, once delay is identified, children may be unable to access services because of unavailability or lack of insurance coverage.

Key Question 4. What Is the Role of Enhanced Surveillance by Primary Care Clinicians?

This question relates to the role of enhanced surveillance by a primary care clinician once a child demonstrates clinical concern for speech and language delay. No studies addressed this question.

Key Question 5. Do Interventions for Speech and Language Delay Improve Speech and Language Outcomes?

Twenty-five randomized controlled trials in 24 publications met inclusion criteria (Table 7; Appendix 9) including one rated good,94 13 fair,95107 and 11 poor quality99, 108117 (Appendix 10). Studies were considered poor quality if they reported important differences between intervention and comparison groups at baseline, did not use intention-to-treat analysis, no method of randomization was reported, and there were fewer than 10 subjects in intervention or comparison groups. Limitations of studies, in general, include small numbers of participants (only 4 studies enrolled more than 50 subjects), lack of consideration of potential confounders, and disparate methods of assessment, intervention, and outcome measurement. As a result, conclusions about effectiveness are limited. Although children in the studies ranged from 18 to 75 months old, most studies included children age 2 to 4 years old and results do not allow determination of optimal ages of intervention.

Table 7. Summary of Randomized Controlled Trials of Interventions.

Table 7

Summary of Randomized Controlled Trials of Interventions.

Studies evaluated the effects of individual or group therapy directed by clinicians and/or parents focusing on specific speech and lanugage domains. These include expressive and receptive language, articulation, phonology, lexical acquisition, and syntax. Several studies used established approaches to therapy, such as the WILSTAAR program118 and the HANEN principles.100, 101, 107, 115 Others used more theoretical approaches, such as focused stimulation,100, 101, 108, 109, 115 auditory discrimination,105, 112 imitation or modeling procedures,98, 114 auditory processing or work mapping,107 and play narrative language.102, 103 Some interventions focused on specific words and sounds, used unconventional methods, or targeted a specific deficit.

Outcomes were measured by subjective reports from parents,99, 100, 102, 107 and by scores on standardized instruments, such as the Reynell Expressive and Receptive Scales,96, 99 the Preschool Language Scale,94, 97, 107 and the MacArthur Communicative Development Inventories.102, 115 The most widely used outcome measure was Mean Length Utterances (MLUs) used by 6 studies.95, 97, 99, 102, 107

Studies rated good or fair quality are described below by age categories according to the youngest ages included, although many studies included children in overlapping categories.

Ages 0 to 2 years. No studies examined this age group exclusively, although one good-quality study enrolled children 18 to 42 months old.94 The clinician-directed, 12-month intervention consisted of 10-minute weekly sessions focusing on multiple language domains, expressive and receptive language, and phonology. Treatment for receptive auditory comprehension lead to significant improvement for the intervention group compared to control group, however, results did not differ between groups for several expressive and phonology outcomes.94

Ages 2 to 3 years. One good94 and 6 fair-quality studies99102, 106, 107 evaluated speech and language interventions for children 2 to 3 years old. Studies reported improvement on a variety of communication domains including clinician-directed treatment for expressive and receptive language,102 parent-directed therapy for expressive delay,99, 100 and clinician-directed receptive auditory comprehension.94 Lexical acquisition was improved with both clinician-directed therapy106, 113 and group therapy approaches.106 In 3 studies, there were no between group differences for clinician-directed expressive94, 107 or receptive language therapy,94, 107 parent-directed expressive or receptive therapy,107 or parent-directed phonology treatment.101

Ages 3 to 5 years. Five fair-quality studies reported significant improvements for children 3 to 5 years old undergoing interventions compared to controls,95, 96, 98, 103, 104 while 2 studies reported no differences.97, 105 Both group-based interventions103 and clinician-directed interventions96 were successful at improving expressive and receptive competencies.

Systematic review. A Cochrane systematic review included a meta-analysis utilizing data from 25 randomized controlled trials of interventions for speech and language delay for children up to adolesence.36 Twenty-three of these studies also met criteria for this review and were included,94114, 117 and 2 trials were unpublished. The review reported results in terms of standard mean differences (SMD) in scores for a number of domains (expressive and receptive phonology, syntax, and vocabulary). Effectiveness was considered significant for both the phonological (SMD=0.44; 95% CI, 0.01–0.86) and vocabulary (SMD=0.89; 95% CI, 0.21–1.56) interventions. Less effective was the receptive intervention (SMD=-0.04; 95% CI, 0.64-0.56), and results were mixed for the expressive syntax intervention (SMD=1.02; 95% CI, 0.04–2.01). In the analysis, when interventions were comparable in duration and intensity, there were no differences between interventions when administered by trained parents or clinicians for expressive delays. Use of normal language peers as part of the intervention strategy also proved beneficial.103

Key Question 6. Do Interventions for Speech and Language Delay Improve Other Non-Speech and Language Outcomes?

Four good94 or fair-quality102, 103, 107 intervention studies included functional outcomes other than speech and language (Table 7; Appendix 9). Increased toddler socialization skills,102 improved child self-esteem,107 and improved play themes103 were reported for children in intervention groups in 3 studies. Improved parent-related functional outcomes included decreased stress102 and increased positive feelings toward their children.107 Functional outcomes studied but not showing significant treatment effects included well being, levels of play and attention, and socialization skills in one study.94

Key Question 7. Does Improvement in Speech and Language Outcomes Lead to Improved Additional Outcomes?

No studies addressed this question.

Key Question 8. What Are the Adverse Effects of Interventions?

No studies addressed this question. Potential adverse effects of treatment programs include the impact of time and cost of interventions on clinicians, parents, children, and siblings. In addition, loss of time for play and family activities, stigmatization, and labeling may be potential adverse effects.

Key Question 9. What Are Cost-Effectiveness Issues?

No studies addressed this question.

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