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  • This publication is provided for historical reference only and the information may be out of date.

This publication is provided for historical reference only and the information may be out of date.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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Speech and language development is considered a useful indicator of a child's overall development and cognitive ability by experts1 and is related to school success.27 Identification of children at risk for developmental delay or related problems may lead to intervention services and family assistance at a young age when chances for improvement are best.1 This rationale supports preschool screening for speech and language delay, or primary language impairment/disorder, as a part of routine well child care.

This evidence synthesis focuses on the strengths and limits of evidence about the effectiveness of screening and interventions for speech and language delay in preschool age children. Its objective is to determine the balance of benefits and adverse effects of routine screening in primary care for the development of guidelines by the U.S. Preventive Services Task Force (USPSTF). The target population includes all children up to age 5 years without previously known conditions associated with speech and language delay, such as hearing and neurological impairments. The evidence synthesis emphasizes the patient's perspective in the choice of tests, interventions, outcome measures, and potential adverse effects, and focuses on those that are available and easily interpreted in the context of primary care. It also considers the generalizability of efficacy studies performed in controlled or academic settings and interprets the use of the tests and interventions in community-based populations seeking primary health care.

Burden of Condition/Epidemiology

Speech and language development in children is a dynamic process. Language encompasses the understanding, processing, and production of communication. Language has been described as a code made up of rules that include what words mean, how to make new words, and how to combine words together.8 Understanding what word combinations are best in what situations is also part of the language code. Speech is the verbal communication of language.8

Several types of speech and language delay and disorders have been described, although terminology varies (Table 1).8 Expressive language delay may exist without receptive language delay but often they occur together in children as a mixed expressive/receptive language delay. Some children also have disordered language. Language problems can involve difficulty with grammar (syntax), words or vocabulary (semantics), the rules and system for speech sound production (phonology), units of word meaning (morphology) and the use of language particularly in social contexts (pragmatics). Speech problems may include stuttering or dysfluency, articulation disorders, or unusual voice quality. Language and speech problems can exist together or by themselves.8

Table 1. Definitions of terms.

Table 1

Definitions of terms.

Prevalence rates for speech and language delay have been reported across wide ranges. A recent Cochrane review summarized prevalence data on speech delay, language delay, and combined delay in preschool and school-aged children.9 For preschool children, 2 to 4.5 years old, studies evaluating combined speech and language delay reported prevalence rates ranging from 5% to 8%,10, 11 and studies of language delay from 2.3% to 19 %.9, 1215 Untreated speech and language delay in preschool children has shown variable persistence rates, from 0% to 100%, with most in the 40% to 60%.9 In one study, two-thirds of preschool children refered for speech and language therapy and given no direct intervention proved eligible for therapy 12 months later.16

Preschool children with speech and language delay may be at increased risk for learning disabilities once they reach school age.17 They may have difficulty reading in grade school,2 exhibit poor reading skills at age 7 or 8,35 and have difficulty with written language,6 in particular. This may lead to overall academic underachievement,7 and, in some cases, lower IQ scores13 that may persist into young adulthood.18 As adults, children with phonological difficulties may hold lower skilled jobs than their non-language impaired siblings.19 In addition to persisting speech and language related underachievement (verbal, reading, spelling), language delayed children have also shown more behavior problems and impaired psychosocial adjustment.20, 21

Healthcare Interventions

Assessing children for speech and language delay and disorders can involve a number of approaches, although there is no uniformly accepted screening technique for use in the primary care setting. Milestones for speech and language development in young children are generally acknowledged (Table 2).8, 22 Concerns for delay arise if there are no verbalizations by the age of one year, if speech is not clear, or if speech or language is different from that of other children of the same age.8 A specific diagnosis is most often made by a specialist utilizing a battery of instruments. Once a child has been diagnosed with a speech and language delay, interventions may be prescribed based on individual needs.

Table 2. Guidelines for Communication and Language Skills by Age.

Table 2

Guidelines for Communication and Language Skills by Age.

Screening. Most formal instruments for assessing speech and language were designed for diagnostic purposes and have not been widely evaluated for screening. Instruments constructed to assess multiple developmental components, such as the Ages and Stages Questionnaire,23 Clinical Adaptive Test/Clinical Linguistic and Auditory Milestone Scale,24 and Denver Developmental Screening Test,25 include speech and language components. Instruments specific to communication domains include the MacArthur Communicative Development Inventory,26 Ward Infant Language Screening Test, Assessment, Acceleration, and Remediation (WILSTAAR),27 Fluharty Preschool Speech and Language,28 Early Language Milestone Scale,29 and several others. In addition, parent questionnaires and parent concern are often used to detect delay.30

Interventions. Therapy takes place in various settings including speech and language specialty clinics, home, and schools or classrooms. Direct therapy or group therapy provided by a clinician, caretaker, or teacher can be child centered and/or include peer and family components. The duration of the intervention varies. Intervention strategies focus on one or more domains depending on individual needs, such as expressive language, receptive language, expressive phonology, receptive phonology, syntax, and lexical acquisition. Therapies can include naming objects, modeling and prompting, individual peer or group play, discrimination tasks, reading, and conversation.

Prior Recommendations and Guidelines

The Canadian Task Force on Preventive Health made recommendations on screening and intervention for global developmental disorders in preschool children, however, these do not focus specifically on speech and language delay.31 The primary test evaluated in the Canadian review, the Denver Developmental Screening Test, included items on language expression and skills of articulation. However, due to limited evidence to support its validity and parental anxiety around use of the test, the Task Force did not recommend it. They also concluded that there was insufficient evidence to support either the inclusion or exclusion of other screening instruments to screen asymptomatic preschool children.

Professional organizations and other groups have recommended various levels of developmental assessment for preschool children. The American Academy of Pediatrics provides detailed interview and examination parameters for physician well child visits from newborn to late adolescence,22 as well as parameters for developmental surveillance and screening of infants to pre-kindergarten children.32 Another guide for physicians, the Harriet Lane Handbook,33 devotes a chapter to development and behavior, describing milestones and recommendations for specific language screening tools for infants and toddlers (Clinical Linguistic and Auditory Milestone Scale)24and preschool aged children (Denver Developmental Assessment-language scales).25 The American Academy of Child and Adolescent Psychiatry has recommendations for older children, however, none specific to preschool children.34

Evaluations of the effectiveness of these guidelines are lacking and it is not clear how consistently clinicians screen for speech and language delay in primary care practice. In one study, 43% of parents reported that their young child (age 10 to 35 months) did not receive any type of developmental assessment at their well child visit, and 30% of parents reported that their child's physician had not discussed how the child communicates.35 Potential barriers to screening include lack of time, no clear protocols, and the competing demands of the primary care visit.

Analytic Framework and Key Questions

The patient population, interventions, outcomes, and adverse effects of screening are summarized in an analytic framework (Figure 1). Corresponding key questions guide the literature review and evidence synthesis (Figure 2). Key questions examine a chain of evidence about the effectiveness, accuracy, and feasibility of screening children age 5 years and younger for speech and language delay in primary care settings (key questions 1 and 2), adverse effects of screening (key question 3), the role of enhanced surveillance in primary care (key question 4), effectiveness of interventions for children identified with delay (key questions 5, 6, and 7), and adverse effects of interventions (key question 8).

Figure 1. Analytic Framework.


Figure 1. Analytic Framework.

Figure 2. Key Questions.


Figure 2. Key Questions.

Studies addressing key question 1, corresponding to the overarching arrow in the analytic framework, would include all components in the continuum of the screening process. These include the screening evaluation, diagnostic evaluation for children identified with delay by the screening evaluation, interventions for children diagnosed with delay, and outcome measures allowing determination of the effectiveness of the overall screening process. Enhanced surveillance in primary care relates to the practice of closely observing children who may have clinical concern for delay but not of the degree warranting a referral (“watchful waiting”). Outcome measures in this review include speech and language specific outcomes as well as non-speech and language health and functional outcomes such as social behavior, self-esteem, family function, peer interaction, and school performance. Key questions 5 examines whether speech and language interventions lead to improved speech and language outcomes. Key question 6 examines whether speech and language interventions lead to improved non-speech and language outcomes. Key question 7 evaluates the downstream effect of improved speech and language, such as improved school performance at a later age.


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