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• Evidence Summary: Speech and Language Delay and Disorders in Children: Screening

Evidence Summary

Speech and language delay and disorders in children: screening, january 23, 2024.

Recommendations made by the USPSTF are independent of the U.S. government. They should not be construed as an official position of the Agency for Healthcare Research and Quality or the U.S. Department of Health and Human Services.

By Cynthia Feltner, MD, MPH; Ina F. Wallace, PhD; Sallie W. Nowell, PhD, CCC-SLP; Colin J. Orr, MD, MPH; Brittany Raffa, MD; Jennifer Cook Middleton, PhD; Jessica Vaughan, MPH; Claire Baker; Roger Chou, MD; Leila Kahwati, MD, MPH

The information in this article is intended to help clinicians, employers, policymakers, and others make informed decisions about the provision of health care services. This article is intended as a reference and not as a substitute for clinical judgment.

This article may be used, in whole or in part, as the basis for the development of clinical practice guidelines and other quality enhancement tools, or as a basis for reimbursement and coverage policies. AHRQ or U.S. Department of Health and Human Services endorsement of such derivative products may not be stated or implied.

This article was published online in JAMA on January 23, 2023 ( JAMA . 2024;331(4):335-351. doi:10.1001/jama.2023.24647).

Importance: Children with speech and language difficulties are at risk for learning and behavioral problems.

Objective: To review the evidence on screening for speech and language delay or disorders in children 5 years or younger to inform the US Preventive Services Task Force.

Data Sources: PubMed/MEDLINE, Cochrane Library, PsycInfo, ERIC, Linguistic and Language Behavior Abstracts (ProQuest), and trial registries through January 17, 2023; surveillance through November 24, 2023.

Study Selection: English-language studies of screening test accuracy, trials or cohort studies comparing screening vs no screening; randomized clinical trials (RCTs) of interventions.

Data Extraction and Synthesis: Dual review of abstracts, full-text articles, study quality, and data extraction; results were narratively summarized.

Main Outcomes and Measures: Screening test accuracy, speech and language outcomes, school performance, function, quality of life, and harms.

Results: Thirty-eight studies in 41 articles were included (N = 9006). No study evaluated the direct benefits of screening vs no screening. Twenty-one studies (n = 7489) assessed the accuracy of 23 different screening tools that varied with regard to whether they were designed to be completed by parents vs trained examiners, and to screen for global (any) language problems vs specific skills (eg, expressive language). Three studies assessing parent-reported tools for expressive language skills found consistently high sensitivity (range, 88%-93%) and specificity (range, 88%-85%). The accuracy of other screening tools varied widely. Seventeen RCTs (n = 1517) evaluated interventions for speech and language delay or disorders, although none enrolled children identified by routine screening in primary care. Two RCTs evaluating relatively intensive parental group training interventions (11 sessions) found benefit for different measures of expressive language skills, and 1 evaluating a less intensive intervention (6 sessions) found no difference between groups for any outcome. Two RCTs (n = 76) evaluating the Lidcombe Program of Early Stuttering Intervention delivered by speech-language pathologists featuring parent training found a 2.3% to 3.0% lower proportion of syllables stuttered at 9 months compared with the control group when delivered in clinic and via telehealth, respectively. Evidence on other interventions was limited. No RCTs reported on the harms of interventions.

Conclusions and Relevance: No studies directly assessed the benefits and harms of screening. Some parent-reported screening tools for expressive language skills had reasonable accuracy for detecting expressive language delay. Group parent training programs for speech delay that provided at least 11 parental training sessions improved expressive language skills, and a stuttering intervention delivered by speech-language pathologists reduced stuttering frequency.

An estimated 8% of US children aged 3 to 17 years have a communication disorder. 1 Boys are almost twice as likely to be affected than girls (9.6% vs 5.7%,) and higher rates are observed among Black children (10%) compared with Hispanic (6.9%) or White (7.8%) children. 1 These data and other nationally representative prevalence estimates are limited in terms of distinguishing children who have a delay vs specific speech and/or language disorder.

A “delay” refers to development of speech and language in the correct sequence but at a slower rate than expected, whereas a “disorder” refers to development of speech and/or language ability that is qualitatively different from typical development. Speech disorders are characterized by difficulty with forming specific sounds or words correctly (articulation or phonological disorders) or making words or sentences flow smoothly (fluency disorders), and language disorders are characterized by difficulty understanding (receptive language) or speaking (expressive language) relative to their peers. 2 The focus of this review is routine screening for developmental (or “primary”) speech or language delay and disorders that are not caused by an injury or another condition (acquired or “secondary” disorders) such as hearing loss (eg, secondary to infection or genetic syndrome) or autism. Evaluation of children with known conditions that affect speech or language development would be part of disease management rather than screening; however, in the context of routine screening, some children who screen positive may go on to receive a primary diagnosis for a disorder such as hearing loss following a diagnostic evaluation.

Many children identified with speech or language delay go on to recover without an intervention. 3 However, observational evidence suggests that school-aged children with speech or language delay may be at increased risk of learning and literacy disabilities. 4-6 and social and behavioral problems, 7 some of which may persist through adulthood. 8 , 9 Screening for speech and language delay is distinct from overall developmental screening recommended by the American Academy of Pediatrics at 18 and 30 months. 10 Children who screen positive require referral for a diagnostic evaluation to confirm the suspected delay or disorder. Once a diagnosis is confirmed, treatment is variable and individualized to the needs of the child based on how the disorder impairs their function in different settings.

In 2015, the US Preventive Services Task Force (USPSTF) concluded that the evidence was insufficient to assess the balance of benefits and harms of screening for speech and language delay and disorders in children 5 years or younger (I statement). 11 The purpose of the current systematic review was to update the previous evidence review on the benefits and harms of screening for speech and language delay and disorders in children to inform the USPSTF in updating its recommendation.

Scope of Review

Figure 1 shows the analytic framework and key questions (KQs) that guided the review. Detailed methods are available in the full evidence review. 12 In addition to the KQs, this review looked for evidence related to 3 contextual questions that focused on disparities in the prevalence, detection, and provision and utilization of treatment for speech and language delay or disorders among specific populations of children (eContextual Questions in the JAMA Supplement).

Data Sources and Searches

PubMed/MEDLINE, the Cochrane Library, APA PsycInfo, ERIC, and Linguistic and Language Behavior Abstracts (ProQuest) were searched for English-language articles published through January 17, 2023 (eMethods in the  JAMA  Supplement). ClinicalTrials.gov was searched for unpublished studies. The searches were supplemented by reviewing reference lists of pertinent articles, studies suggested by peer reviewers, and comments received during public commenting periods. From January 17, 2023, through November 24, 2023, ongoing surveillance was conducted through article alerts and targeted searches of journals to identify major studies published in the interim that may affect the conclusions or understanding of the evidence and the related USPSTF recommendation.

Study Selection

Two investigators independently reviewed titles, abstracts, and full-text articles using prespecified eligibility criteria (eTable 4 in the JAMA  Supplement). Disagreements were resolved by discussion and consensus. For all KQs, English-language studies enrolling unselected children 5 years or younger from primary care or primary care–relevant settings (including childcare, schools, and other education settings) who communicate using any language were eligible. In addition, only studies set in countries categorized as “very high” on the Human Development Index 13 and rated as fair or good quality were included. For studies assessing the benefits and harms of interventions (KQ4, KQ5, and KQ6), those enrolling children referred for treatment or identified by educators or parents as having a possible speech or language problem, and those enrolling children up to age 6 years were also eligible.

For KQ2, studies assessing the accuracy of a screening instrument against a diagnosis reference standard (diagnostic interview, diagnostic questionnaire, or both) were included. Eligible screening instruments had to be feasible for use in primary care and included short questionnaires that could be delivered and interpreted in 10 minutes or less in clinical settings and longer questionnaires completed by parents or teachers outside of a scheduled visit. Studies focusing on the accuracy of general developmental screening tools that did not include a separate component for speech and language skills were excluded.

Randomized clinical trials (RCTs), nonrandomized clinical trials, and controlled cohort studies were eligible for KQ1 and KQ3 (benefit and harms of screening compared with no screening) and KQ6 (harms of interventions compared with an inactive control). For studies reporting on the benefit of interventions to improve speech and language outcomes (KQ4) or academic skills, behavior, function, or quality of life (KQ5), RCTs comparing an intervention with an inactive control were eligible. For KQ4, KQ5, and KQ6, eligible interventions included any treatment designed to improve speech and/or language delay or disorders among eligible populations, regardless of format (eg, individual or group settings, face-to-face, or via telehealth) or delivery personnel (eg, speech-language pathologists [SLPs] or other clinicians, parents, or teachers).

Data Extraction and Quality Assessment

For each included study, 1 investigator extracted pertinent information about the methods, populations, interventions, comparators, outcomes, timing, settings, and study designs. All data extractions were checked by a second investigator for completeness and accuracy. For newly identified studies, 2 reviewers independently assessed each study’s methodological quality using predefined criteria developed by the USPSTF (eMethods in the JAMA  Supplement) and informed by tools designed for various study designs (Cochrane Risk of Bias 2.0 tool for RCTs; 14 Quality Assessment of Diagnostic Accuracy Studies 2 for screening test accuracy). 15 For eligible studies included in the previous update for this topic, quality ratings were spot-checked and carried forward. Disagreements were resolved by discussion.

Data Synthesis and Analysis

Findings for each KQ were summarized in tabular and narrative format. The overall strength of the evidence for each KQ was assessed as high, moderate, low, or insufficient based on the overall quality of the studies, consistency of results between studies, precision of findings, risk of reporting bias, and limitations of the body of evidence using methods developed for the USPSTF (and the Evidence-based Practice Center program). 16 , 17 Additionally, the applicability of the findings to US primary care populations and settings was assessed. Discrepancies were resolved through consensus discussion.

For studies included for KQ2 (accuracy of screening tools), sensitivity, specificity, likelihood ratios, and predictive values were calculated based on data reported by articles, when sufficient, to compare consistency across similar measures. To determine whether meta-analyses were appropriate, the clinical heterogeneity and methodological heterogeneity of the studies were assessed following established guidance. 18 Due to heterogeneity in populations, outcome measures and other factors, as well as few studies assessing the same screening tool or interventions, meta-analysis was not appropriate.

A total of 38 studies (reported in 41 articles) were included ( Figure 2 ) in the review. Individual study quality ratings are reported in eTables 5 through 10 in the  JAMA  Supplement.

Benefits of Screening

Key Question 1. Does screening for speech and language delay or disorders in children age 5 years or younger improve speech and language outcomes, school performance, function, or quality-of-life outcomes?

No eligible study addressed this question.

Accuracy of Screening

Key Question 2. What is the accuracy of screening tools to detect speech and language delay or disorders in children age 5 years or younger?

Twenty-one studies (reported in 23 articles) assessed the accuracy of 23 screening instruments for detecting speech and language delay and disorders in young children against a reference standard (n = 7489) ( Table 1 ). 19-41 Seven studies were new to this update. 24 , 27 , 30-32 , 39 , 41 Of the 23 instruments,13 19-23 , 28-32 , 35 , 37 , 38 were designed to be administered to children by a trained examiner, and 10 23-27 , 33-36 , 39-41 were parent reports of children’s speech or language skills ( Table 2 ).

Some screening tools, termed global screening tools, screen for any language problems, while others provide scores for specific aspects of language (eg, expressive communication, receptive language, vocabulary). Twelve global screening tools were evaluated in the studies included the Ages and Stages Questionnaire (ASQ), 23 , 41 the Davis Observation Checklist for Texas, 19 the Developmental Nurse Screen, 35 the Early Language Scale, 39 the Fluharty Preschool Screening Test (FPST), 20 the General Language Screen, 36 the Hackney Early Language Screening Test/Structured Screening Test (HELST/SST), 28 , 29 the Infant-Toddler Checklist, 40 the Nurse Screening, 30 , 31 the Parent Questionnaire, 35 the Screening Kit of Language Development (SKOLD)/Screening Kit of Language Development Black English (SKOLDBE), 21 and the language component of the Sentence Repetition Screening Test (SRST). 38

Nine other tools provided scores for specific aspects of language, including the Brigance Preschool Screen, 23 the Early Screening Profiles, 23 the Battelle the Elternfragebogen für die Fruberkennung von Riskokindern (ELFRA-2), 33 , 34 the Sprachentwicklungsscreening (SPES-3) instrument, 24 the Language Development Survey (LDS), 25 , 26 the Quick Interactive Language Screener (QUILS), 32 the Sure Start Language Measure (SSLM), 41 the Northwestern Syntax Screening Test, 20 and the Battelle Developmental Inventory Screening Test–Communication. 23 Three of the trained examiner tools specifically screened for articulation skills—the Denver Articulation Screening Exam 22 and the articulation portion of both the Fluharty Preschool Speech and Language Screening Test (FPSLST) 37 and the SRST 38 —and 1 parent-administered instrument measured articulation. 27 The articulation instruments were considered separately from specific language instruments. All but 3 instruments (ie, ASQ, 23 , 41 HELST/SST, 28 , 29 and Nurse Screening 30 , 31 ) were examined in only 1 study each. In addition, 2 studies examined the FPST 20 and a later version with a language component, the FPSLST. 37

Excluding 2 studies 33 , 40 that enrolled all children who screened positive and a random sample of children who screened negative, the prevalence of speech and language disorders based on reference standards ranged from 4% to 33% ( Table 3 ).

Accuracy of Instruments

As shown in Table 3 , the sensitivity of instruments for detecting speech and language disorders and delay ranged from 17% and 100% (median, 86%), and specificity ranged between 32% and 98% (median, 87%). To further examine accuracy, the source of the information (parent report vs trained examiner) and whether the instrument was designed as a global index of speech or language, a specific language skill (eg, word knowledge), or a measure of articulation were considered.

Parent Reported

Sensitivity and specificity of 14 parent-reported tools varied widely ( Table 3 ). Sensitivity ranged from 55% to 93% (median, 84%) and specificity ranged from 32% to 96% (median, 84%).

Global Language vs Specific Language vs Articulation . Limiting analysis to global language instruments based on parent reports, median sensitivity was 74%, ranging between 55% and 89%. Specificity was less variable, ranging between 73% and 95% (median, 79%). In contrast, both sensitivity and specificity of the 3 parent-reported instruments of specific skills (all emerging expressive language skills) were fairly consistent and high (median sensitivity, 91% [range, 83%-93%]; median specificity, 88% [range, 81%-96%]). The 1 parent-rated measure of articulation had a reasonably high sensitivity (86%) but low specificity (32%).

Trained Examiners

The median sensitivity of the 13 screening tools that trained examiners administered to children was 87% (range, 17%-100%), and the median specificity was 88% (range, 58% to 98%). Similar to parent-reported instruments, there is substantial variability in the accuracy of examiner-administered tools.

Global Language vs Specific Language vs Articulation . Restricting the accuracy summary to trained examiner screenings of global language resulted in median sensitivity of 88% (range, 17%-100%) and median specificity of 89% (69%-98%). The median sensitivity of trained examiner instruments for specific language skills was 86% (range, 56%-94%) and median specificity was 70% (range, 58%-90%). Across the 3 trained examiner tools for assessing articulation, the median sensitivity was only 66% (range, 43%-92%); however, median specificity was 96% (range, 93%-97%).

Harms of Screening

Key Question 3. What are the harms of screening for speech and language delay or disorders in children age 5 years or younger?

Benefits of Treatment

Key Question 4. Do interventions for speech and language delay or disorders in children age 6 years or younger improve speech and language outcomes?

Seventeen RCTs (18 articles) compared an intervention for speech and language delay or disorders with an inactive control (no treatment or wait-list control/delayed treatment). 42-59 Study characteristics are shown in eTable 11 in the  JAMA  Supplement. No studies enrolled children identified by routine screening in primary care. Most recruited participants from referrals to speech and language treatment centers (6 studies), 42 , 47 , 49 , 50 , 53 , 54 schools or early childhood education centers (4 studies), 43 , 46 , 48 , 56 or via advertisements or a mix of advertisements and outreach to schools, clinical settings, or community-based programs. 44 , 45 , 55 , 57 The mean age of enrolled populations ranged from 18.1 months to 67.8 months, with most (10 studies) enrolling a sample with a mean age of 48 months or older. The proportion of participants who were female ranged from 10% to 49%. Few studies reported on race or ethnicity; in 3 studies set in the US, populations were described as 100% Latino, 45 100% White, 57 and 1 was inclusive of different groups (2% American Indian, 3% Asian, 2% Black, 26% Hispanic, 12% multiracial, 54% White). 48 Interventions evaluated were heterogeneous and varied in terms of the range of disorders targeted, delivery personnel, intensity/duration, settings, and other factors (eTable 11 in the  JAMA  Supplement).

Eight RCTs assessed interventions specific to children with delayed expressive language (“late talkers”) and no obvious fluency or speech-sound impairment. 44 , 45 , 50-52 , 56-59 Of these, 3 RCTs evaluated parent-group training interventions focused on strategies to promote their child’s language development; training approaches and specific content varied, but all focused on naturalistic strategies (eg, expanding on child utterances, following the child’s interests, repeating what the child says, setting up the environment to encourage communication). Of these, 2 RCTs assessed modifications of the Hanen Program for Parents curriculum (featuring a combination of group training sessions composed of a small group of parents and a trained SLP or other trained facilitator, and individual consultations with the SLP while the child is present), 51 , 58 and 1 evaluated a similar group training program focused on improving child linguistic complexity. 50 Results varied by duration of the intervention and mean age of enrolled populations. In 2 RCTs in which the intervention was delivered to children with a mean age of 27 to 30 months over a longer duration (11 bimonthly 60- to 75-minute sessions in one of the trials 50 and 11 weekly 2.5-hour sessions plus 3 weekly home visits in the other trial 51 ), there was consistent benefit across different measures of expressive language outcomes (eTable 12 in the  JAMA  Supplement). The RCT delivering the parent group training to children with a mean age of 18 months over a shorter duration (6 weekly 2-hour sessions) found no significant difference between groups on any measure of receptive or expressive language outcomes. 58

Five other RCTs assessed different interventions for children with language delay and varied in terms of setting, delivery personnel, and other factors. 44 , 45 , 56 , 57 , 59 In general, results were inconsistent, with some studies showing improvement on some measures of receptive or expressive language but others not. Results are further summarized in the eResults and eTable 12 in the  JAMA  Supplement.

Two RCTs assessed fluency treatment for young children. Both focused on the Lidcombe Program of Early Stuttering Intervention. 54 , 55 This intervention is led by an SLP who trains parents to provide verbal contingencies for stutter-free speech (eg, “that was smooth talking”) and stuttering (eg, “that was a bit bumpy”) and requests for self-evaluation and self-correction (eg, “can you say that again”). In one of these RCTs, the intervention was delivered in a face-to-face format in a clinical setting 54 and in the other it was delivered via telehealth. 55 Results were consistent in showing a statistically significant improvement in stuttering fluency associated with the intervention. In the face-to-face intervention, children in the intervention group had a 2.3% (95% CI, 0.8-3.9) lower proportion of syllables stuttered than children in the control group at 9 months. Per the authors, this is above the minimum clinically important difference of 1.0% of syllables stuttered (the minimum difference that a listener would be able to distinguish). 54 However, no reference or clear rationale was provided to support this threshold. In the RCT using telehealth delivery of the intervention, the difference between the intervention and control group in change from baseline mean number of syllables stuttered was −3.0% ( P = .02) at 9 months. 55

Evidence on other intervention types targeting specific speech or language problems was limited and is further described in the eResults in the  JAMA  Supplement.

Key Question 5. Do interventions for speech and language delay or disorders in children age 6 years or younger improve school performance, function, or quality-of-life outcomes?

Eight RCTs reported on 1 or more outcomes specific to school performance, function, or quality of life using heterogeneous measures. 42 , 43 , 47 , 48 , 53 , 57-59 Characteristics are described above in KQ4 and detailed results are shown in eTable 15 in the  JAMA  Supplement. No RCTs assessing a similar intervention type reported on the same outcome domain, and most studies reporting on similar domains (eg, early literacy) used different outcome measures. In 4 RCTs reporting on a measure of early or emergent literacy skills, 3 found no significant difference between groups. 42 , 43 , 48 In contrast, 1 RCT assessing a home-based language delay intervention delivered by trained assistants found benefit for improving letter knowledge associated with the intervention. 59 Two RCTs reported on 1 or more measures of functional communication 42 , 47 and quality of life/wellbeing in children 43 , 53 and found no difference between groups, while 1 RCT evaluating an individual intervention for language delay found significant improvement favoring the intervention for improving child socialization skills and parental stress levels. 57

Harms of Treatment

Key Question 6. What are the harms of interventions for speech and language delay or disorders?

This systematic review synthesized evidence relevant to screening for speech and language delay or disorders in children 5 years or younger. Table 4 summarizes the main findings of the evidence review. There was no direct evidence on the benefits and harms of screening (KQ1). Potential harms of screening (KQ3) include false-positive results that can lead to unnecessary referrals (and the associated time and economic burden), labeling or stigma, parent anxiety, and other psychosocial harms. Other harms of screening are likely to be minimal because screening is noninvasive.

The studies of screening test accuracy (KQ2) included in this review assessed 23 different tools that varied in terms of whether they were completed by parents vs trained examiners and whether they were designed to detect global speech or language problems vs problems related to specific language skills or articulation. Some screening tools usable in clinical practice may identify children who have a speech or language disorder with reasonable sensitivity and specificity. However, overall evidence was mixed and few screening tools were assessed by more than 1 study each, limiting the ability to make stronger conclusions about the accuracy of specific tools. Parent-reported screening instruments designed to assess expressive language skills displayed consistently high sensitivity and specificity, although precision varied by instrument. In contrast, the accuracy of the parent-reported instruments for global language skill assessment was inconsistent, and precision varied across instruments. The accuracy of examiner-administered screening instruments varied, particularly for instruments designed to assess specific language skills.

Few studies of interventions for speech and language delay or disorder enrolled similar populations and evaluated similar types of interventions (KQ4). Although 2 RCTs of treatment enrolled children newly referred from primary care, it is not clear whether the children were identified via routine screening vs case finding. Other included studies enrolled children referred or recruited via advertisements, and most focused on a specific type of speech delay or disorder. Given these factors, the body of evidence on treatment available for inclusion in this review may not be applicable to the type and severity of disorders that would be detected via routine screening in primary care settings.

Studies of children referred for language delay without obvious speech-sound or fluency disorder suggested that group training interventions offering at least 11 parent training sessions improved expressive language outcomes. For children identified with stuttering, the Lidcombe Program of Early Stuttering Intervention delivered by SLPs improved stuttering fluency at 9 months when delivered either in person or via telehealth. Although 8 RCTs reported on 1 or more outcomes specific to school performance or early literacy, health-related quality of life, function, behavior, or socialization (KQ5), the interventions and populations evaluated were heterogeneous, which limited the ability to assess consistency; most studies found no difference between groups for measures of early literacy, function, and quality of life. However, most trials may not have followed up children for a long enough duration to detect an improvement in quality of life or function that could result from early treatment of a speech and language delay or disorder. No RCTs reported on the harms of interventions; however, given the nature of the interventions, serious harms are unlikely.

Trials are needed that enroll asymptomatic or unselected populations from general primary care settings and directly assess the benefit of screening specifically for speech and language problems. The control groups in these trials could receive either no screening or routine screening for general developmental delay, with no separate score for speech and language problems. Studies are also needed on the potential harms of screening, such as labeling, and harms from false-positive results, such as burden on parents due to unnecessary referrals. Such studies would also inform the potential for overdiagnosis associated with routine screening, given that many children who have a speech delay may recover without intervention. 3

Similarly, studies assessing the accuracy of screening tools among unselected populations, who are ideally recruited through primary care settings, are needed because the prevalence of speech and language problems may vary compared with populations enrolled via advertisements or specialty settings. Specifically, studies that assess the accuracy of existing tools, compared with similar reference standards, would help determine the consistency of findings; because few included studies evaluated the same instrument, our ability to make a strong conclusion about accuracy was limited. Trials of treatment enrolling populations recruited from US primary care settings would help inform the potential benefit of screening because the range of severity and conditions is likely different compared with trials that enroll referred populations. Last, studies that followup children for a sufficiently long duration to detect improvement in academic performance, function, and quality of life would help in the understanding of whether immediate changes in speech and language outcomes (eg, short-term expansion of vocabulary words) translate into benefit for health and social outcomes.

Limitations

This review excluded studies in children who had a condition known to cause a speech or language problem (eg, hearing loss, autism) to improve the applicability of evidence to populations likely to be detected by routine screening. Studies evaluating primary prevention strategies to promote speech and language development (eg, interventions among groups considered “at risk” or school-based curricula emphasizing language development among children with no developmental delay or disorder) were also excluded. The aim was to limit the review to interventions that are relevant to children with screen-detected speech and language problems and that are appropriate to deliver in primary care settings or refer to from primary care.

This review found no eligible studies that reported on direct benefits or harms of screening compared with usual care or no screening. Parent-reported screening tools for expressive language delay had reasonable accuracy. In contrast, parent-reported screening tools for global language delay had inconsistent accuracy. The accuracy of examiner-administered instruments was also variable, especially for examiner-administered instruments of specific language skills. Existing evidence on treatment of speech and language delay is available from referral populations but not from screen-detected populations. This evidence indicates the benefit from group parent-training programs for speech delay that provide at least 11 parental training sessions for improving expressive language skills, as well as the Lidcombe Program of Early Stuttering Intervention delivered by SLPs for reducing stuttering frequency. Few studies reported on outcomes specific to school performance, function, quality of life, or behavior, and none reported on the harms of interventions.

Source: This article was published online in JAMA on January 23, 2023 ( JAMA . 2024;331(4):335-351. doi:10.1001/jama.2023.24647).

Conflict of Interest Disclosures: None reported.

Funding/Support: None reported.

Role of the Funder/Sponsor: Investigators worked with USPSTF members and AHRQ staff to develop the scope, analytic framework, and key questions for this review. AHRQ had no role in study selection, quality assessment, or synthesis. AHRQ staff provided project oversight, reviewed the evidence review to ensure that the analysis met methodological standards, and distributed the draft for peer review. Otherwise, AHRQ had no role in the conduct of the study; collection, management, analysis, and interpretation of the data; and preparation, review, or approval of the manuscript findings. The opinions expressed in this document are those of the authors and do not reflect the official position of AHRQ or the US Department of Health and Human Services.

Additional Contributions: We gratefully acknowledge the following individuals for their contributions to this project, including AHRQ staff (Justin Mills, MD, MPH; Tracy Wolff, MD, MPH), Scientific Resource Center for the AHRQ Evidence-based Practice Center Program staff (Robin A. Paynter, MLIS), Pacific Northwest Evidence-based Practice Center staff (Christina Bougatsos, MPH), and RTI International–University of North Carolina–Chapel Hill Evidence-based Practice Center staff (Manny Schwimmer, MPH; Christiane E. Voisin, MSLS; Roberta Wines, MPH; Mary Gendron; Sharon Barrell, MA; Alexander Cone; Teyonna Downing; Michelle Bogus). The USPSTF members, expert reviewers, and federal partner reviewers did not receive financial compensation for their contributions. Evidence-based Practice Center personnel received compensation for their roles in this project.

Additional Information: A draft version of the full evidence review underwent external peer review from 3 content experts (Abigail D. Delehanty, PhD, CCC-SLP, Duquesne University; Virginia Moyer, MD, MPH, University of North Carolina at Chapel Hill; Thelma E. Uzonyi, PhD, CCC-SLP, IMH-E, Kennedy Krieger Institute) and 3 federal partner reviewers (Centers for Disease Control and Prevention; Eunice Kennedy Shriver National Institute of Child Health and Human Development; and National Institute on Deafness and Other Communication Disorders). Comments from reviewers were presented to the USPSTF during its deliberation of the evidence and were considered in preparing the final evidence review. USPSTF members and peer reviewers did not receive financial compensation for their contributions.

1. Black LI, Vahratian A, Hoffman HJ. Communication disorders and use of intervention services among children aged 3-17 years: United States, 2012. NCHS Data Brief . 2015;(205):1-8. 2. Centers for Disease Control and Prevention. Language and speech disorders in children. Published 2021. Accessed January 24, 2023. https://www.cdc.gov/ncbddd/developmentaldisabilities/language-disorders.html 3. Law J, Boyle J, Harris F, et al. Prevalence and natural history of primary speech and language delay: findings from a systematic review of the literature. Int J Lang Commun Disord . 2000;35(2):165-188. doi:10.1111/j.1460-6984.2000.tb00001. 4. Lewis BA, Freebairn L, Tag J, et al. Adolescent outcomes of children with early speech sound disorders with and without language impairment. Am J Speech Lang Pathol . 2015;24(2):150-163. doi:10.1044/2014_AJSLP-14-007 5. Catts HW, Bridges MS, Little TD, Tomblin JB. Reading achievement growth in children with language impairments. J Speech Lang Hear Res . 2008;51(6):1569-1579. doi:10.1044/1092-4388(2008/07-0259) 6. Conti-Ramsden G, St Clair MC, Pickles A, Durkin K. Developmental trajectories of verbal and nonverbal skills in individuals with a history of specific language impairment: from childhood to adolescence. J Speech Lang Hear Res . 2012;55(6):1716-1735. doi:10.1016/j.ridd.2013.08.043 7. Glogowska M, Roulstone S, Peters TJ, Enderby P. Early speech- and language-impaired children: linguistic, literacy, and social outcomes. Dev Med Child Neurol . 2006;48(6):489-494. doi:10.1017/S0012162206001046 8. Dubois P, St-Pierre MC, Desmarais C, Guay F. Young adults with developmental language disorder: a systematic review of education, employment, and independent living outcomes. J Speech Lang Hear Res . 2020;63(11):3786-3800. doi:10.1044/2020_JSLHR-20-00127 9. Schoon I, Parsons S, Rush R, Law J. Children’s language ability and psychosocial development: a 29-year follow-up study. Pediatrics . 2010;126(1):e73-e80. doi:10.1542/peds.2009-3282 10. Lipkin PH, Macias MM; Council on Children With Disabilities, Section on Developmental and Behavioral Pediatrics. Promoting optimal development: identifying infants and young children with developmental disorders through developmental surveillance and screening. Pediatrics . 2020;145(1):e20193449. doi:10.1542/peds.2019- 3449 11. Siu AL; US Preventive Services Task Force. Screening for speech and language delay and disorders in children aged 5 years or younger: US Preventive Services Task Force recommendation statement. Pediatrics . 2015;136(2):e474-e481. doi:10.1542/peds.2015-1711 12. Feltner C, Wallace IF, Nowell S, et al. Screening for Speech and Language Delays and Disorders in Children Age 5 Years or Younger: An Evidence Review for the US Preventive Services Task Force . Evidence Synthesis No. 234. Agency for Healthcare Research and Quality; 2023. AHRQ publication 23-05306-EF-1. 13. United Nations Development Programme. Human Development Report 2020: the next frontier: human development and the Anthropocene. Published 2020. Accessed January 24, 2023 http://report2020.archive.s3-website-useast-1.amazonaws.com/ 14. Sterne JAC, Savović J, Page MJ, et al. RoB 2: a revised tool for assessing risk of bias in randomised trials. BMJ . 2019;366:l4898. doi:10.1136/bmj.l4898 15. Whiting PF, Rutjes AW,Westwood ME, et al; QUADAS-2 Group. QUADAS-2: a revised tool for the quality assessment of diagnostic accuracy studies. Ann Intern Med . 2011;155(8):529-536. doi:10.7326/0003-4819-155-8-201110180-00009 16. US Preventive Services Task Force Procedure Manual. Published May 2021. Accessed January 24, 2023. https://uspreventiveservicestaskforce.org/uspstf/about-uspstf/methods-and-processes/procedure-manual 17. Agency for Healthcare Research and Quality Effective Health Care Program. Methods guide for effectiveness and comparative effectiveness reviews. Published content last reviewed October 2022. Accessed January 24, 2023 https://effectivehealthcare.ahrq.gov/products/collections/cer-methods-guid e 18. West SL, Gartlehner G, Mansfield AJ, et al. Comparative Effectiveness Review Methods: Clinical Heterogeneity . Agency for Healthcare Research and Quality; 2010. 19. Alberts FM, Davis BL, Prentice L. Validity of an observation screening instrument in a multicultural population. J Early Interv . 1995;19(2):168-177. doi:10.1177/105381519501900209 20. Allen DV, Bliss LS. Concurrent validity of two language screening tests. J Commun Disord . 1987;20(4):305-317. doi:10.1016/0021-9924(87)90012-8 21. Bliss LS, Allen DV. Screening Kit of Language Development: a preschool language screening instrument. J Commun Disord . 1984;17(2):133-141. doi:10.1016/0021-9924(84)90019-4 22. Drumwright A, Van Natta P, Camp B, Frankenburg W, Drexler H. The Denver articulation screening exam. J Speech Hear Disord . 1973;38(1):3-14. doi:10.1044/jshd.3801.03 23. Frisk V, Montgomery L, Boychyn E, et al. Why screening Canadian preschoolers for language delays is more difficult than it should be. Infants Young Child . 2009;22(4):290-308. doi:10.1097/IYC.0b013e3181bc 24. Holzinger D,Weber C, Barbaresi W, Beitel C, Fellinger J. Language screening in 3-year-olds: development and validation of a feasible and effective instrument for pediatric primary care. Front Pediatr . 2021;9:752141. doi:10.3389/fped.2021.752141 25. Klee T, Carson DK, Gavin WJ, Hall L, Kent A, Reece S. Concurrent and predictive validity of an early language screening program. J Speech Lang Hear Res . 1998;41(3):627-641. doi:10.1044/jslhr.4103.627 26. Klee T, Pearce K, Carson DK. Improving the positive predictive value of screening for developmental language disorder. J Speech Lang Hear Res . 2000;43(4):821-833. doi:10.1044/jslhr.4304.821 27. Kok ECE, To CKS. Revisiting the cutoff criteria of Intelligibility in Context Scale–Traditional Chinese. Lang Speech Hear Serv Sch . 2019;50(4):629-638. doi:10.1044/2019_LSHSS-18-0073 28. Laing GJ, Law J, Levin A, Logan S. Evaluation of a structured test and a parent-led method for screening for speech and language problems: prospective population based study. BMJ . 2002;325(7373):1152. doi:10.1136/bmj.325.7373.1152 29. Law J. Early language screening in city and Hackney: the concurrent validity of a measure designed for use with 2 1/2-year-olds. Child Care Health Dev . 1994;20(5):295-308. doi:10.1111/j.1365-2214.1994.tb00392.x 30. Nayeb L, Lagerberg D, Westerlund M, Sarkadi A, Lucas S, Eriksson M. Modifying a language screening tool for three-year-old children identified severe language disorders six months earlier. Acta Paediatr . 2019;108(9):1642-1648. doi:10.1111/apa.14790 31. Nayeb L, Lagerberg D, Sarkadi A, Salameh EK, Eriksson M. Identifying language disorder in bilingual children aged 2.5 years requires screening in both languages. Acta Paediatr . 2021;110(1):265-272. doi:10.1111/apa.15343 32. Pace A, Curran M, Van Horne AO, et al. Classification accuracy of the Quick Interactive Language Screener for preschool children with and without developmental language disorder. J Commun Disord . 2022;100:106276. doi:10.1016/j.jcomdis.2022.106276 33. Sachse S, Von Suchodoletz W. Early identification of language delay by direct language assessment or parent report? J Dev Behav Pediatr. 2008;29(1):34-41. doi:10.1097/DBP.0b013e318146902a 34. Sachse S, von Suchodoletz W. Response to reader comments on Early identification of language delay by direct language assessment or parent report?. J Dev Behav Pediatr . 2009;30(2):176. doi:10.1097/DBP.0b013e31819f1c9f 35. Stokes SF. Secondary prevention of paediatric language disability: a comparison of parents and nurses as screening agents. Eur J Disord Commun . 1997;32(2 spec No):139-158. doi:10.1111/j.1460-6984.1997.tb01628.x 36. Stott CM, Merricks MJ, Bolton PF, Goodyer IM. Screening for speech and language disorders: the reliability, validity and accuracy of the General Language Screen. Int J Lang Commun Disord . 2002;37(2):133-151. doi:10.1080/13682820110116785 37. Sturner RA, Heller JH, Funk SG, Layton TL. The Fluharty Preschool Speech and Language Screening Test: a population-based validation study using sample-independent decision rules. J Speech Hear Res . 1993;36(4):738-745. doi:10.1044/jshr.3604.738 38. Sturner RA, Funk SG, Green JA. Preschool speech and language screening: further validation of the sentence repetition screening test. J Dev Behav Pediatr . 1996;17(6):405-413. doi:10.1097/00004703-199612000-00006 39. Visser-Bochane MI, van der Schans CP, Krijnen WP, Reijneveld SA, Luinge MR. Validation of the Early Language Scale. Eur J Pediatr . 2021;180(1):63-71. doi:10.1007/s00431-020-03702-8 40. Wetherby AM, Goldstein H, Cleary J, Allen L, Kublin K. Early identification of children with communication disorders. Infants Young Child . 2003;16(2):161-174. doi:10.1097/00001163-200304000-00008 41. Wilson P, Rush R, Charlton J, Gilroy V, McKean C, Law J. Universal language development screening: comparative performance of two questionnaires. BMJ Paediatr Open . 2022;6(1):e001324. doi:10.1136/bmjpo-2021-001324 42. McLeod S, Davis E, Rohr K, et al. Waiting for speech-language pathology services: a randomised controlled trial comparing therapy, advice and device. Int J Speech Lang Pathol . 2020;22(3):372-386. doi:10.1080/17549507.2020.1731600 43. McLeod S, Baker E, McCormack J, et al. Cluster-randomized controlled trial evaluating the effectiveness of computer-assisted intervention delivered by educators for children with speech sound disorders. J Speech Lang Hear Res . 2017;60(7):1891-1910. doi:10.1044/2017_JSLHR-S-16-0385 44. Thordardottir E, Cloutier G, Ménard S, Pelland-Blais E, Rvachew S. Monolingual or bilingual intervention for primary language impairment? a randomized control trial. J Speech Lang Hear Res . 2015;58(2):287-300. doi:10.1044/2014_JSLHR-L-13-0277 45. Peredo TN, Mancilla-Martinez J, Durkin K, Kaiser A. Teaching Spanish-speaking caregivers to implement EMT en Español: a small randomized trial. Early Child Res Q . 2022;58:208-219. doi:10.1016/j.ecresq.2021.08.004 46. Acosta-Rodríguez VM, Ramírez-Santana GM, Hernández-Expósito S. Intervention for oral language comprehension skills in preschoolers with developmental language disorder. Int J Lang Commun Disord . 2022;57(1):90-102. doi:10.1111/1460-6984.12676 47. Namasivayam AK, Huynh A, Granata F, Law V, van Lieshout P. PROMPT intervention for children with severe speech motor delay: a randomized control trial. Pediatr Res . 2021;89(3):613-621. doi:10.1038/s41390-020-0924-4 48. Wilcox MJ, Gray S, Reiser M. Preschoolers with developmental speech and/or language impairment: efficacy of the Teaching Early Literacy and Language (TELL) curriculum. Early Child Res Q . 2020;51:124-143. doi:10.1016/j.ecresq.2019.10.005 49. Almost D, Rosenbaum P. Effectiveness of speech intervention for phonological disorders: a randomized controlled trial. Dev Med Child Neurol . 1998;40(5):319-325. doi:10.1111/j.1469-8749.1998.tb15383.x 50. Gibbard D. Parental-based intervention with pre-school language-delayed children. Eur J Disord Commun . 1994;29(2):131-150. doi:10.3109/13682829409041488 51. Girolametto L, Pearce PS, Weitzman E. Interactive focused stimulation for toddlers with expressive vocabulary delays. J Speech Hear Res . 1996;39(6):1274-1283. doi:10.1044/jshr.3906.1274 52. Girolametto L, Pearce PS, Weitzman E. Effects of lexical intervention on the phonology of late talkers. J Speech Lang Hear Res . 1997;40(2):338-348. doi:10.1044/jslhr.4002.338 53. Glogowska M, Roulstone S, Enderby P, Peters TJ. Randomised controlled trial of community based speech and language therapy in preschool children. BMJ . 2000;321(7266):923-926. doi:10.1136/bmj.321.7266.923 54. Jones M, Onslow M, Packman A, et al. Randomised controlled trial of the Lidcombe Programme of Early Stuttering Intervention. BMJ . 2005;331(7518):659. doi:10.1136/bmj.38520.451840.E0 55. Lewis C, Packman A, Onslow M, Simpson JM, Jones M. A phase II trial of telehealth delivery of the Lidcombe Program of Early Stuttering Intervention. Am J Speech Lang Pathol . 2008;17(2):139-149. doi:10.1044/1058-0360(2008/014 56. Robertson SB, Ellis Weismer S. The influence of peer models on the play scripts of children with specific language impairment. J Speech Lang Hear Res . 1997;40(1):49-61. doi:10.1044/jslhr.4001.49 57. Robertson SB, Ellis Weismer S. Effects of treatment on linguistic and social skills in toddlers with delayed language development. J Speech Lang Hear Res . 1999;42(5):1234-1248. doi:10.1044/jslhr.4205.1234 58. Wake M, Tobin S, Girolametto L, et al. Outcomes of population based language promotion for slow to talk toddlers at ages 2 and 3 years: Let’s Learn Language cluster randomised controlled trial. BMJ . 2011;343:d4741. doi:10.1136/bmj.d4741 59. Wake M, Tobin S, Levickis P, et al. Randomized trial of a population-based, home-delivered intervention for preschool language delay. Pediatrics . 2013;132(4):e895-e904. doi:10.1542/peds.2012-3878

Evidence reviews for the US Preventive Services Task Force (USPSTF) use an analytic framework to visually display the key questions that the review will address to allow the USPSTF to evaluate the effectiveness and safety of a preventive service. The questions are depicted by linkages that relate interventions and outcomes. A dashed line depicts a health outcome that follows an intermediate outcome. For additional information, see the USPSTF Procedure Manual. 16 , 17

ERIC indicates Education Resources Information Center; KQ, key question; LLBA, Linguistics and Language Behavior Abstracts; USPSTF, US Preventive Services Task Force; and WHO ICTRP,World Health Organization International Clinical Trials Registry Platform. a The sum of the number of studies per KQ exceeds the total number of studies because some studies were applicable to multiple KQs.

Abbreviations: ASQ, Ages and Stages Questionnaire; ASQ-CD, ASQ–Communication Domain; BDIST-CD, Battelle Developmental Inventory Screening Test–Communication Domain; BPS, Brigance Preschool Screen; CDI, MacArthur-Bates Communicative Development Inventory; CSBS, Communication and Symbolic Behavior Scales; DASE, Denver Articulation Screening Exam; DNS, Developmental Nurse Screen; DOCT, Davis Observation Checklist for Texas; ELFRA-2, Elternfragebogen für die Fruberkennung von Riskokindern; ELS, Early Language Scale; ESP, Early Screening Profiles; FPSLST, Fluharty Preschool Speech and Language Screening Test; FPST, Fluharty Preschool Screening Test; GLS, General Language Screen; HELST, Hackney Early Language Screening Test; ICS-TC, Intelligibility in Context Scale–Traditional Chinese; ITC, Infant-Toddler Checklist; KQ, key question; LDS, Language Development Survey; NR, not reported; NSST, Northwestern Syntax Screening Test; QUILS, Quick Interactive Language Screening; SKOLD, Screening Kit of Language Development; SKOLDBE, Screening Kit of Language Development Black English; SPES-3, Sprachentwicklungsscreening; SRST, Sentence Repetition Screening Test; SSLM, Sure Start Language Measure; SST, Structured Screening Test; WIC, Women, Infants, and Children. a Full sample size, based on multiple imputation. b Includes 11 children (10.5%) who did not cooperate during screening and were considered screen positive. c Includes 11 children who were noncooperative during screening. For Model 4, parents of 10 children did not complete parental information. d Based on full sample.

Abbreviations: CDI, MacArthur-Bates Communicative Development Inventory; CSBS, Communication and Symbolic Behavior Scales; ELFRA-2, Elternfragebogen für die Fruberkennung von Riskokindern; KQ, key question; NR, not reported; SPES-3, Sprachentwicklungsscreening; WH questions, who, when, where, why, what, and how. a Only the Battelle Developmental Inventory Test Receptive Language Scale is included in accuracy analyses. b Although the SPES-3 was designed as both a parent-reported and trained examiner instrument, the authors recommended that only the parent-reported subscales be included as a screen for language delay; therefore, the SPES-3 was classified as a parent-reported instrument.

Abbreviations: AAPS-R, Arizona Articulation Proficiency Scale–Revised; ASQ-CD, Ages and Stages Questionnaire–Communication Domain; AWST-R, AktiverWortschatztest für 3-bis 5-jährige Kinder; BDIST-CD, Battelle Developmental Inventory Screening Test–Communication Domain; BLST, Bankson Language Screening Test; BPS, Brigance Preschool Screen; CCC-2, Children’s Communication Checklist, 2nd Edition–Netherlands; CDI, MacArthur-Bates Communicative Development Inventory; CSBS, Communication and Symbolic Behavior Scales; DASE, Denver Articulation Screening Exam; DNS, Developmental Nurse Screen; DOCT, Davis Observational Checklist for Texas; DP-II, Developmental Profile II; ELFRA-2, Elternfragebogen für die Fruberkennung von Riskokindern; ELS, Early Language Scale; ESP, Early Screening Profiles; FPSLST, Fluharty Preschool Speech and Language Screening Test; FPST, Fluharty Preschool Screening Test; GFTA, Goldman-Fristoe Test of Articulation; GLS, General Language Screen; HAT, Henja Articulation Test; HELST, Hackney Early Language Screening Test; HKCAT, Hong Kong Cantonese Articulation Test; ICS-TC, Intelligibility in Context Scale–Traditional Chinese; ITC, Infant-Toddler Checklist; ITPA, Illinois Test of Psycholinguistic Abilities; LDS, Language Development Survey; LLC, Lexilist Comprehension; LLP, Lexilist Production; LR+, positive likelihood ratio; LR–, negative likelihood ratio; LS, Language Standard; MLU, mean length of utterance; MSCA, McCarthy Scales of Children’s Abilities; MSEL, Mullen Scales of Early Learning; NPV, negative predictive value; NR, not reported; NSST, Northwestern Syntax Screening Test; PLS-4-C, Preschool Language Scale, Fourth Edition–Comprehension, PLS-4-E, Preschool Language Scale, Fourth Edition–Expression; PLS-5, Preschool Language Scale, Fifth Edition; PPV, positive predictive value; QUILS, Quick Interactive Language Screener; RDLS, Reynell Developmental Language Scales; ROC, receiver operating characteristic; SETK-2, Sprachentwicklungstest für zweijahrige Kinder; SETK-3, Sprachentwicklungstest für zweijahrige Kinder; SICD, Sequenced Inventory of Communication Development; SKOLD, Screening Kit of Language Development; SKOLDBE, Screening Kit of Language Development Black English; SLC, Schlichting Tests for Language Comprehension; SLP, speech-language pathologist; SPES-3, Sprachentwicklungsscreening; SSP, Schlichting Tests for Sentence Production; SRST, Sentence Repetition Screening Test; SSLM, Sure Start Language Measure; SST, Structured Screening Test; SWP, Schlichting Tests for Word Production; TACL-R, Test for Auditory Comprehension of Language–Revised; TD, Templin-Darley Tests of Articulation Consonant Singles Subtest; TOLD-P, Test of Language Development Primary. a Calculated by the Evidence-based Practice Center. b Optimal cut point using Youden index. c Prevalence not reported for this subsample. Median for sensitivity/specificity includes full sample only and not the English-speaking subsample. d Prevalence for screen failures more than 1.5 SD below the mean is 18%; study calculated accuracy using this value as well as prevalence using cut point of more than 2 SDs below the mean, which was 6%. Data were included for only the former prevalence. e Sample size and prevalence based on imputed sample, which corrected for oversampling of children with positive screening results. f Prevalence data provided by study authors. g Includes 11 children who were noncooperative during screening. h The study investigators weighted the ns based on a stratified sample of 69. i Only the BDIST-CD Receptive Scale is included in accuracy analyses.

Abbreviations: ANOVA, analysis of variance; ASQ, Ages and Stages Questionnaire; DOCT, Davis Observational Checklist for Texas; ELFRA-2, Elternfragebogen für die Fruberkennung von Riskokindern; ELS, Early Language Scale; HELST, Hackney Early Language Screening Test; KQ, key question; LDS, Language Development Survey; LR–, negative likelihood ratio; LR+, positive likelihood ratio; NA, not applicable; QOL, quality of life; RCT, randomized clinical trial; SKOLD, Screening Kit of Language Development; SLP, speech-language pathologist; SPES-3, Sprachentwicklungsscreening; SRST, Sentence Repetition Screening Test; SST, Structured Screening Test. a Frisk et al 23 examined 3 instruments and included separate accuracy calculations for the expressive and receptive PLS-4 reference measure. Accuracy outcomes were omitted for the Battelle Developmental Inventory Screening Test with the PLS-4 Expressive Communication Scale due to a possible reporting error in the study.

Speech Delay

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Speech delay is the diagnosis given to children who exhibit normal language development, but their speech production skills fall below those expected based on their chronological age and level of cognitive or intellectual functioning (Vinson, 2007 ). Speech-language pathologists use standardized language tests to diagnose speech delay. While the etiology underlying the delay may be unknown, speech delay has been associated with a variety of developmental disorders including autism spectrum disorders. Predictors of long-term speech delay in late-talking toddlers at 30–35 months include limited phonetic inventory, simple syllable structures, more sound errors, greater inconsistency in substitution errors, atypical errors, and slow rate of resolution (Williams & Elbert, 2003 ). Speech therapy may be provided to children with a diagnosis of speech delay with the goal of helping them attain communication skills that are commensurate with their chronological/developmental age (Roth...

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References and Readings

Late Blooming or Language Problem. (n.d.). In American-Speech-Language-Hearing-Association Typical Speech and Language development. Retrieved February 3, 2011, from http://www.asha.org/public/speech/disorders/LateBlooming.htm

Roth, F. P., & Worthington, C. K. (2010). Treatment resource manual for speech-language pathology (4th ed.). Independence, KY: Cengage Learning.

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Vinson, B. (2007). Language disorders across the lifespan (2nd ed.). Clifton Park, NY: Thomson Delmar Learning.

Williams, A. L., & Elbert, M. (2003). A prospective longitudinal study of phonological development in Late Talkers. Language, Speech, and Hearing Services in Schools, 34 , 138–153.

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Bean, A. (2013). Speech Delay. In: Volkmar, F.R. (eds) Encyclopedia of Autism Spectrum Disorders. Springer, New York, NY. https://doi.org/10.1007/978-1-4419-1698-3_1700

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Speech and language delay in children: a case to learn from

Introduction.

Speech and language delay in children is a common presentation to primary care either directly to the GP or through the health visitor, affecting approximately 6% of pre-school children. 1 Young children, particularly those with speech delay, can be difficult to examine. Differentiation between an isolated pathology and those with concurrent global developmental delay is crucial. This article presents an example of a common case, considers the learning points, and highlights management principles.

CASE HISTORY

A 2-year-old boy presented to primary care with fewer words than his peers, and with difficulty in non-family members understanding him. On closer questioning he had <10 words of speech. He was born at 39 weeks by normal delivery, not requiring special care baby unit, and passed his newborn hearing screening. Review of his Personal Child Health Record (red book) showed consistent growth along centile lines, and other developmental milestones attained. In the consultation room he played appropriately, made good eye contact, and followed instructions: identifying his nose and ears when asked. On examination, he had normal facies, and otoscopy revealed bilateral dull tympanic membranes.

Referral to audiology was made and age- appropriate free-field hearing testing with tympanometry performed. He had hearing thresholds of >40 dB (mild-to-moderate hearing loss) with flat tympanograms indicating a conductive loss in keeping with otitis media with effusion (OME).

For 3 months the child was actively observed and then referred to the ear, nose, and throat consultant. With evidence of persistent conductive hearing loss, he was offered hearing aids or grommets, in keeping with National Institute for Health and Care Excellence guidelines. 2 His parents elected for grommet insertion. On follow-up at 2 years, 6 months, his vocabulary had expanded to >100 words, and audiogram showed thresholds <20 dB in the normal range.

ASSESSMENT AND DIFFERENTIAL DIAGNOSIS

Speech and language delay must be separated from variation in speech development, and is defined by children falling behind recognised milestones. Regression or loss of speech and language are particularly concerning.

Initially, a history with a focus on identifying a cause for the speech delay should be taken, including pregnancy and birth history, developmental milestones, and family history.

Aspects of the antenatal history that may impact on newborn hearing must be explored. These include TORCH interuterine infections (toxoplasmosis, rubella, cytomegalovirus, and herpes simplex) and maternal drug exposure. Important aspects of the perinatal history include prematurity, hypoxia, birth trauma, and neonatal jaundice. Newborn hearing screening does not occur worldwide and should not be assumed in births outwith the UK. General maternal health is useful, particularly for the exclusion of conditions such as hypothyroidism.

The child’s medical history should be covered, including conditions such as meningitis, head trauma, and seizures, and exposure to ototoxic drugs. Developmental milestones should be noted, including social interactions with peers and family. This is not only to explore the possibility of a global developmental delay/disorder and the possibility of an underlying psychological diagnosis, but may also highlight deprivation and neglect.

It is important to enquire about any family history of hearing loss and speech delay including the possibility of consanguinuity, which may point to metabolic or recessive conditions.

In multilingual children total words across all languages should be counted, and will often compensate for the perceived delay. 5

Examination should be global, observing behaviour but with a focus on otoscopy, which may provide instant diagnosis of common conditions such as OME. Observed or formal neurological assessment of fine and gross motor skills may highlight a global development delay, with head circumference a useful adjunct.

There are multiple causes of speech delay, which can be split into psychological, neurological, and otological ( Figure 1 ). There is a known association between confirmed speech and language delay and psychiatric disorders such as autism spectrum disorder, with up to 50% occurring concurrently. 6

Venn diagram demonstrating the different causes of speech and language delay (adapted from the Oxford Handbook of Paediatrics 4 ). OME = otitis media with effusion. TORCH = toxoplasmosis, rubella, cytomegalovirus, and herpes simplex.

In syndromic children, especially those with craniofacial abnormalities the speech delay may be multifactorial and a multidisciplinary approach with multiple referrals required.

One of the challenges in assessing a child with speech and language delay is that the order of learning and speech and language acquisition is fixed, but there is significant variation in timings described. 7 Up to 60% of children with speech delay do not require intervention and the problem resolves spontaneously by 3 years of age. 1 It is therefore important to undertake an individualised approach to each child.

Diagnosis of the underlying causation of speech delay is the priority and guides management. All children with suspected speech delay should be referred for audiometry to exclude hearing loss as this is a potentially reversible cause in the setting of OME with appropriate intervention.

Other causes that should not be missed include global developmental delay and psychiatric disorders such as autism spectrum disorder, both of which will require a multidisciplinary approach with enhanced potential outcomes for the child if support and treatment are offered earlier. Ultimately these children will require input from a child development centre.

Children with craniofacial abnormalities, for example, Down’s syndrome, may suffer from both conductive deafness and development delay, which will be confounded if not treated.

In the case described the child was suffering from speech delay secondary to OME. This is the commonest cause of hearing impairment in the developed world 8 and is reversible. OME has two peaks of incidence at 2 and 5 years. 9 The current treatment strategy for OME is grommet insertion after a recommended 3-month period of watchful waiting 2 to allow for spontaneous effusion resolution. Hearing aids are a non-surgical alternative but are generally seen as socially unacceptable. Twenty-five per cent of children will require further grommet insertion within 2 years of the first, 10 with a mean number of grommet insertions per child of 2.1. 11 This emphasises the recurrent nature of OME and the importance of close follow-up for these children.

Speech and language delay may be an early presenting feature in children with global developmental delay, and provides a crucial early opportunity to intervene and provide multidisciplinary support. Prompt audiological assessment is essential in all children with speech and language delay to exclude reversible causes.

Patient consent

The case presented here is fictional and therefore consent was not required.

Freely submitted; externally peer reviewed.

Competing interests

The authors have declared no competing interests.

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Speech & Language Delay

• by Selina.Chow
• Feb 16, 2024

This PedsCases note provides a one-page overview about speech & language delay, including its risk factors, diagnosis, associated conditions and management. It was created by Selina Chow, a medical student at the University of Toronto with the help of Dr. Rhea D'Costa, a developmental pediatrician at the University of Toronto. 

Click the image below for a full-screen handout . 

Related content:

Podcast: Speech and Language Delay

Case: Speech delay in a 2 year old boy

Note:  Crucial skills - First Six Years developmental attainments charts

Note:  Crucial skills - School Age developmental attainments chart

Andrews D, Dosman C. Snapshots Developmental Milestones. Division of Developmental Pediatrics, University of Alberta. 2014. Available at: https://pedscases.com/sites/default/files/SNAPSHOTS_Developmental_Milest...

Bishop DV, Clarkson B. Written language as a window in to residual language deficits: a study of children with persistent and residual speech and language impairments. Cortex. 2003 Dec 31;39(2):215-37.

Catts HW, Fey ME, Tomblin JB, Zhang X. A longitudinal investigation of reading outcomes in children with language impairments. Journal of speech, Language, and hearing Research. 2002 Dec 1;45(6):1142-57.

Law J, Garrett Z, Nye C. Speech and language therapy interventions for children with primary speech and language delay or disorder. Campbell Collaboration; 2003.

Leung AK, Kao CP. Evaluation and management of the child with speech delay. Am Fam Physician. 1999 Jun;59(11):3121-8, 3135. PMID: 10392594.

McLaughlin MR. Speech and language delay in children. American family physician. 2011 May 15;83(10):1183.

Moharir M, Barnett N, Taras J, Cole M, Ford-Jones EL, Levin L. Speech and language support: how physicians can identify and treat speech and language delays in the office setting. Paediatrics &amp; child health. 2014 Jan;19(1):13.

Nelson HD, Nygren P, Walker M, Panoscha R. Screening for speech and language delay in preschool children: systematic evidence review for the US Preventive Services Task Force. Pediatrics. 2006 Feb 1;117(2):e298-319.

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Speech and Language Delay in Children

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Barry Prizant

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"Good communication skills have emerged as a key social skill in modern day society. Children are not exempt from this pressure to communicate effectively. Paradoxically so perhaps because of this pressure there is an increasing awareness of delays in language development in children. Whether because of this increasing awareness or because of other biological, social and environmental causes the incidence of communication disorders in children has risen sharply in the last couple of decades. Given the increasing emphasis on good communication skills in modern day schools and society this has necessitated that children with these disorders be identified early and provided with early intervention in order to prevent the cascading negative consequences to a given child. The paper describes the major subtypes of communication disorders found in children, their causes, why they need to be identified early and how this can be done. The paper concludes with a note on intervention possibilities and the need for increasing awareness among physicians, pediatricians in particular."

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The focal point of this research study is the language acquisition process and the linguistic development of 1-3 year-old children. It examines the three factors that impact language learning, i.e (1) the parents’ contribution to the learning of phonological, morphological, and syntactic structures, (2) the intelligence level, and (3) the sociability. For a period of two years, the researcher traced the linguistic progress and observed all the linguistic aspects of the development of two male Lebanese children whose native language is Arabic, from the age of one till the age of three for the elder child and from birth till the age of two for the younger one, through recording and pursuing the emergence of new naturalistic unprompted sounds, morphemes, syntactical constructions, and whole utterances. She also observed how parents’ reinforcement of the linguistic structures, their children’s level of intelligence and sociability affected their interaction with the environment as well as their communicative competence. The findings of the study show that in spite of the fact that the three factors were the same for both children, the acquisition of the elder is remarkably better than that of the younger one. This is a solid proof of the mentalist theories of language innateness that conceive the existence of a Language Acquisition Device (LAD), which enables children to acquire language at different rates because of the variability in the activity of cells in the Broca’s area of the left hemisphere of the brain. Imitation played a significant role in the language development of the younger child whose vocabulary jumped from a few words to a wide range within a period of two months only. Hence, based on the observations and the analysis of the results, the researcher recommends that parents, primary caregivers, and teachers gain an extensive understanding of this period of life (1-3 years of age) to contribute to boosting language learning and enhancing their children’s myriad linguistic abilities.

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• Corpus ID: 45420100

Speech and language delay in children.

• M. Mclaughlin
• Published in American Family Physician 15 May 2011

Tables from this paper

126 Citations

Management of developmental speech and language disorders: part 1, the clinical features of preschool children with speech and language disorder and the role of maternal language, speech language disorder in children: an overview, frequency of intellectual disability in children with speech delay, an assessment of risk factors of delayed speech and language in children: a cross-sectional study, influence factors, impact and interventions for speech delay and language delay in early childhood : systematic review, prevalence and risk factors of primary speech and language delay in children less than seven years of age, assessment of speech and language delay using language evaluation scale trivandrum(lest 0-3) original article, detection of speech delayed in children using iterative dichotomiser 3 (id3) algorithm: prematurity, gender, family history of speech delay, education, and occupation, what an otolaryngologist should know about evaluation of a child referred for delay in speech development., 36 references, evaluation of the child with delayed speech or language., evaluation and management of the child with speech delay., screening for speech and language delay in preschool children: recommendation statement, speech and language therapy interventions for children with primary speech and language delay or disorder..

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Speech and language therapy to improve the communication skills of children with cerebral palsy.

Intervention for childhood apraxia of speech., written language as a window in to residual language deficits: a study of children with persistent and residual speech and language impairments, speech therapy for children with dysarthria acquired before three years of age., the cambridge language and speech project (clasp). i . detection of language difficulties at 36 to 39 months., psychosocial outcomes at 15 years of children with a preschool history of speech-language impairment., related papers.

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Please note:  This information was current at the time of publication but now may be out of date. This handout provides a general overview and may not apply to everyone. 

Am Fam Physician. 2023;108(2):online

Related article: Speech and Language Delay in Children

What is speech and language delay?

Speech and language delay can cause your child to have problems saying words and phrases, understanding what is being said, or putting feelings, thoughts, and ideas into words.

Every child develops at their own pace, but some children are behind in speech development compared with other children the same age because of speech and language delay. Your doctor may think that your child has speech delay if they aren't able to:

Use at least three words by 15 months of age

Follow one-step directions by 18 months of age

Use two-word phrases by two years of age

Follow two-step directions by two-and-a-half years of age

Speak well enough for others to understand them most of the time by three years of age

What causes speech and language delay?

The most common causes include developmental delays, hearing loss, or intellectual disability.

Other causes include:

Cerebral palsy (seh-REH-bral PAWL-zee): a movement disorder caused by damage to the brain

Dysarthria (diss-AR-three-uh): problems with the muscles used for speech

Selective mutism: not talking in certain settings

Autism: a developmental disorder

Will it affect my child if we speak two languages at home?

Children who are raised speaking two languages might mix up the two languages when first learning to talk, but they tend to meet the same milestones as children who speak only one language.

How will my doctor know if my child has speech and language delay?

Your doctor will evaluate your child's speech and mental and physical development. He or she may also test your child for hearing problems.

How is it treated?

Your doctor might refer your child to a speech therapist to help them learn to understand and speak better. A speech therapist can also teach you new ways to encourage your child. Your doctor might also refer your child to another specialist, such as an audiologist, if another condition is causing speech delay or if there is concern for hearing loss.

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