Conclusions
Studies are not available addressing the overarching key question about
the effectiveness of screening (key question 1), adverse effects of screening
(key question 3), the role of enhanced surveillance in primary care (key
question 4), long-term effectiveness of interventions on non-speech and
language outcomes for children identified with delay (key questions 7), and
adverse effects of interventions (key question 8). No studies determine the optimal ages and
frequency for screening (key question 2d).
Relevant studies are available regarding the
use of risk factors for screening (key question 2a), techniques for screening
(key question 2b and 2c), and effectiveness of interventions on short-term
speech and language and non-speech and language outcomes for children
identified with delay (key questions 5 and 6).
The use of risk factors for selective
screening has not been evaluated and a list of specific risk factors to guide
primary care physicians has not been developed or tested. Sixteen
studies about potential risk factors for speech and language delay in children
enrolled heterogeneous populations, had dissimilar inclusion and exclusion
criteria, and measured different risk factors and outcomes. The most
consistently reported risk factors included a family history of speech and
language delay, male gender, and perinatal factors. Other risk factors that
were reported less consistently included educational levels of the mother and
father, childhood illnesses, birth order, and family size.
Although brief evaluations are available
and have been used in a number of settings with administration by professional
and nonprofessional individuals, including parents, the optimal method of
screening for speech and language delay has not been established. The performance characteristics of evaluation
techniques taking 10 minutes or less to administer were described in 24 studies
relevant to screening. Studies rated good-to-fair quality
reported wide ranges of sensitivity and specificity when compared with reference
standards (sensitivity 31% to 100%; specificity 45% to 100%). In these studies,
the instruments providing the highest sensitivity and specificity included the
Early Language Milestone Scale, Clinical Linguistic and Auditory Milestone
Scale, Language Development Survey, Screening Kit of Language Development, and
the Levett-Muir Language Screening Test. Most of the evaluations, however, were
not designed for screening purposes, the instruments measured different
domains, and the study populations and settings were often outside primary
care. No gold standard has been
developed and tested for screening, reference standards varied across studies,
few studies compared the performance of 2 or more screening techniques in 1
population, and comparisons of a single screening technique across different
populations are lacking.
RCTs of multiple types of interventions reported significantly improved speech and
language outcomes compared with control groups. Improvement was demonstrated in
several domains including articulation, phonology, expressive language,
receptive language, lexical acquisition, and syntax among children in all age
groups studied and across multiple therapeutic settings. However, studies were
small, heterogeneous, may be subject to plateau effects, and reported
short-term outcomes based on various instruments and measures. As a result, long-term outcomes are not known, interventions could not be directly compared to determine optimal
approaches, and generalizability is questionable.
There are many limitations of the literature
relevant to screening for speech and language delay in preschool-aged children
including lack of studies specific to screening as well as difficulties
inherent in this area of research. This
evidence review is limited by use of only published studies of instruments and
interventions. Data about performance
characteristics of instruments, in particular, are not generally accessible and
are often only available in manuals that must be purchased. Interventions vary widely and may not be
generalizable. In addition, studies from
countries with different health care systems, such as the U.K., may not
translate well to U.S. practice.
Although speech and language development is multi-dimensional, the individual constructs
that comprise it are often assessed separately.
Numerous evaluation instruments and interventions that accommodate
children across a wide range of developmental stages have been developed to
identify and treat specific abnormalities of these functions. As a result, studies include many different
instruments and interventions that are most often designed for purposes other
than screening. Also, studies of
interventions typically focus on 1 or a few interventions. In clinical practice, children are provided
with individualized therapies consisting of multiple interventions. The
effectiveness of these complex interventions may be difficult to evaluate.
Adapting results of this heterogeneous literature to determine benefits and
adverse effects of screening is problematic.
Also, behavioral interventions are difficult to
conduct in long-term randomized trials, and it is not possible to blind parents
or clinicians. Randomizing children to therapy or control groups when clinical
practice standards support therapy raises ethical dilemmas.
Speech and language
delay is defined by measurements on diagnostic instruments in terms of a
position on a normal distribution.
Measures and terminology are inconsistently used and there is no
recognized gold standard. This is
challenging when defining cases and determining performance characteristics of
screening instruments in studies.
Identification of
speech and language delay may be associated with benefits and adverse effects
that would not be captured by studies of clinical or health outcomes. The process of screening alerts physicians
and caretakers to developmental milestones and focuses attention on the child's
development, potentially leading to increased surveillance, feelings of
caregiver support, and improved child self esteem. Alternatively, caretakers and children may
experience increased anxiety and stress during the screening and evaluation
process. Detection of other conditions
during the course of speech and language evaluation, such as hearing loss, is
an unmeasured benefit if appropriate interventions can improve the child's
status.
Future research
should focus on determining optimal approaches of identifying preschool
children with speech and language delay in primary care settings who would be
appropriate candidates for further evaluations and possibly speech and language
interventions.These approaches should
be integrated into routine developmental surveillance practices of clinicians
caring for children.97
Studies that evaluate the effectiveness of validated brief screening
instruments that include child and caretaker components could lead to a more
standardized approach. Studies of specific speech and language components of
currently available broad developmental screening instruments, such as Ages and
Stages, would be useful. Incorporation
of risk factors and parent report in studies of screening approaches could
provide information about their added value.
Additional studies that compare screening instruments and methods in
large primary care populations could lead to defining gold standards and
acceptable referral criteria. Evaluating
these criteria in different populations of children would minimize cultural and
language biases.
Additional work about
the effectiveness of interventions, including speech and language domain-specific
results, may provide new insights.
School-based efforts could be designed to complement strategies
developed for young children improving long-term outcomes. Results of these studies may help determine
optimal ages and intervals for screening. Functional long-term outcomes such as
school performance, high school
graduation rates, in-grade retention, special education placement/duration, and
social adjustment
need to be addressed more thoroughly. Cost-effectiveness evaluations of effective
approaches that consider cost of treatment, the time that caregivers spend in
transit to treatment locations, the time they spend participating in the
program on site or in the home, and long-term outcomes, among other factors,
would be useful.
Return to Contents
Acknowledgments
The investigators thank Andrew Hamilton, M.L.S., M.S.,
for conducting the literature searches, expert reviewers for commenting on
draft versions of this report, and members of the USPSTF
who served as leads for this project including Alfred Berg, M.D., M.P.H.; Paul
Frame, M.D.; Leon Gordis, M.D., Dr.P.H.; Jonathan Klein, M.D., M.P.H.; Virginia
Moyer, M.D., M.P.H.; and Barbara Yawn, M.D., M.Sc.
This study was conducted by the Oregon Evidence-based Practice
Center under contract to the Agency for Healthcare Research and Quality,
Contract #290-02-0024, Task Order Number 2, Rockville, MD.
Return to Contents
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Return to Contents
Notes
Author Affiliations
All Oregon Health and Science University, Portland, Oregon.
[a] Department of Medical
Informatics and Clinical Epidemiology.
[b] Department of Medicine.
[c] Department of Pediatrics.
[d] The Oregon Evidence-based Practice Center.
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Source: 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;117:e298-e319.
Return to Contents
Current as of February 2006
Internet Citation:
Nelson HD, Nygren P, Walker M, Panoscha R. Screening for Speech
and Language Delay in Preschool Children: Systematic Evidence Review for the U.S.
Preventive Services Task Force. Originally in Pediatrics 2006;117:e298-e319. February
2006. Agency for Healthcare Research and Quality, Rockville, MD.
http://www.ahrq.gov/clinic/uspstf06/speech/speechrev.htm
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