Screening for Speech and LanguageDelay and Disorders in Children Aged5 Years or Younger: US PreventiveServices Task Force RecommendationStatementAlbert L. Siu, MD, MSPH, on behalf of the US Preventive Services Task Force

abstract BACKGROUND: This report is an update of the US Preventive Services Task Force(USPSTF) 2006 recommendation on screening for speech and language delayin preschool-aged children.

METHODS: The USPSTF reviewed the evidence on screening for speech andlanguage delay and disorders in children aged 5 years or younger, includingthe accuracy of screening in primary care settings, the role of surveillance byprimary care clinicians, whether screening and interventions lead to improvedoutcomes, and the potential harms associated with screening andinterventions.

POPULATION: This recommendation applies to asymptomatic children aged5 years or younger whose parents or clinicians do not have specific concernsabout their speech, language, hearing, or development.

RECOMMENDATION: The USPSTF concludes that the current evidence is insufficientto assess the balance of benefits and harms of screening for speech andlanguage delay and disorders in children aged 5 years or younger(I statement).

The US Preventive Services TaskForce (USPSTF) makesrecommendations about theeffectiveness of specific preventivecare services for patients withoutrelated signs or symptoms.

It bases its recommendations on theevidence of both the benefits and harmsof the service and an assessment of thebalance. The USPSTF does not considerthe costs of providing a service in thisassessment.

The USPSTF recognizes that clinicaldecisions involve more considerationsthan evidence alone. Clinicians shouldunderstand the evidence butindividualize decision-making to thespecific patient or situation. Similarly,

the USPSTF notes that policy andcoverage decisions involveconsiderations in addition to theevidence of clinical benefits andharms.

SUMMARY OF RECOMMENDATION ANDEVIDENCE

The USPSTF concludes that the currentevidence is insufficient to assess thebalance of benefits and harms ofscreening for speech and languagedelay and disorders in children aged5 years or younger (I statement). (Seethe Clinical Considerations section forsuggestions for practice regarding theI statement.)

Recommendations made by the US PreventiveServices Task Force are independent of the USgovernment. They should not be construed as anofficial position of the Agency for HealthcareResearch and Quality or the US Department ofHealth and Human Services.

www.pediatrics.org/cgi/doi/10.1542/peds.2015-1711

DOI: 10.1542/peds.2015-1711

Accepted for publication May 20, 2015

Address correspondence to USPSTF Senior ProjectCoordinator, 540 Gaither Rd, Rockville, MD 20850.E-mail: coordinator@uspstf.net

PEDIATRICS (ISSN Numbers: Print, 0031-4005; Online,1098-4275).

Copyright © 2015 by the American Academy ofPediatrics

FINANCIAL DISCLOSURE: The author has indicated hehas no financial relationships relevant to this articleto disclose.

FUNDING: The US Preventive Services Task Force(USPSTF) is an independent, voluntary body. The USCongress mandates that the Agency for HealthcareResearch and Quality support the operations of theUSPSTF.

POTENTIAL CONFLICT OF INTEREST: The author hasindicated he has no potential conflicts of interest todisclose.

COMPANION PAPER: A companion to this article canbe found on page e448, online at www.pediatrics.org/cgi/doi/10.1542/peds.2014-3889.

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RATIONALE

Importance

Speech and language delays anddisorders can pose significantproblems for children and theirfamilies. Children with speech andlanguage delays develop speech orlanguage in the correct sequence butat a slower rate than expected,whereas children with speech andlanguage disorders develop speech orlanguage that is qualitatively differentfrom typical development.Differentiating between delays anddisorders can be complicated. First,screening instruments have difficultydistinguishing between the 2. Second,although the majority of school-agedchildren with language disorderspresent with language delays astoddlers, some children outgrow theirlanguage delay.1

Information about the prevalence ofspeech and language delays anddisorders in young children in theUnited States is limited. In 2007,∼2.6% of children ages 3 to 5 yearsreceived services for speech andlanguage disabilities under theIndividuals With DisabilitiesEducation Act (IDEA).2 In 1population-based study in 8-year-olds in Utah, the prevalence ofchildren with communicationdisorders (speech or language) on thebasis of special education orInternational Classification ofDiseases, Ninth Revision,classifications was 63.4 cases per1000 children.3 The prevalence ofisolated communication disorders(ie, children without a concomitantdiagnosis of autism spectrumdisorder or intellectual disability)was 59.1 cases per 1000 children.

Information on the natural history ofspeech and language delays anddisorders, including how outcomesmay change as a result of screening ortreatment, is also limited.

Detection

The USPSTF found inadequateevidence on the accuracy of screeninginstruments for speech and languagedelay for use in primary care settings.Several factors limited theapplicability of the evidence toroutine screening in primary caresettings.

The USPSTF also found inadequateevidence on the accuracy ofsurveillance (active monitoring) byprimary care clinicians to identifychildren for further evaluation forspeech and language delays anddisorders.

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Benefits of Early Detection andIntervention

The USPSTF found inadequateevidence on the benefits of screeningand early intervention for speech andlanguage delay and disorders inprimary care settings.

The USPSTF found inadequateevidence on the effectiveness ofscreening in primary care settings forspeech and language delay anddisorders on improving speech,language, or other outcomes.Although the USPSTF found evidencethat interventions improve somemeasures of speech and language forsome children, there is inadequateevidence on the effectiveness ofinterventions in children detected byscreening in a primary care setting.

The USPSTF found inadequateevidence on the effectiveness ofinterventions for speech andlanguage delay and disorders onoutcomes not specific to speech(eg, academic achievement, behavioralcompetence, socioemotionaldevelopment, and quality of life).

Harms of Early Detection andIntervention

The USPSTF found inadequateevidence on the harms of screening inprimary care settings andinterventions for speech andlanguage delay and disorders inchildren aged 5 years or younger.

USPSTF Assessment

The USPSTF concludes that theevidence is insufficient and that thebalance of benefits and harms ofscreening and interventions forspeech and language delay anddisorders in young children inprimary care settings cannot bedetermined.

CLINICAL CONSIDERATIONS

Patient Population UnderConsideration

This recommendation applies only toasymptomatic children whose

parents or clinicians do not havespecific concerns about their speech,language, hearing, or development. Itdoes not apply to children whoseparents or clinicians raise thoseconcerns; these children shouldundergo evaluation and, if needed,treatment.

This recommendation discusses theidentification and treatment of“primary” speech and language delaysand disorders (ie, in children who havenot been previously identified withanother disorder or disability that maycause speech or language impairment).

Suggestions for Practice Regardingthe I Statement

Potential Preventable Burden

Information about the prevalence ofspeech and language delays anddisorders in young children in theUnited States is limited. In 2007,∼2.6% of children ages 3 to 5 yearsreceived services for speech andlanguage disabilities under IDEA.2

Childhood speech and languagedisorders include a broad set ofdisorders with heterogeneousoutcomes. Information about thenatural history of these disorders islimited, because most affectedchildren receive at least some type ofintervention. However, there is someevidence that young children withspeech and language delay may be atincreased risk of language-basedlearning disabilities.4

Potential Harms

The potential harms of screening andinterventions for speech andlanguage disorders in young childrenin primary care include the time,effort, and anxiety associated withfurther testing after a positive screen,as well as the potential detrimentsassociated with diagnostic labeling.However, the USPSTF found nostudies on these harms.

Current Practice

Surveillance or screening for speechand language disorders is commonly

recommended as part of routinedevelopmental surveillance andscreening in primary care settings(ie, during well-child visits).5 Inpractice, however, such screening isnot universal. The previous evidencereview6 found that 55% of parentsreported that their toddler did notreceive any type of developmentalassessment at their well-child visit,and 30% of parents reported thattheir child’s health care provider hadnot discussed with them how theirchild communicates.7 In a 2009 study,approximately half of respondingpediatricians reported that they“always or almost always” usea standardized screening tool todetect developmental problems inyoung children; ∼40% of respondentsreported using the Ages and StagesQuestionnaire (ASQ).8 The USPSTFdistinguishes between screening inprimary care settings and diagnostictesting, which may occur in othersettings.

Assessment of Risk

On the basis of a review of 31 cohortstudies, several risk factors have beenreported to be associated with speechand language delay and disorders,including male sex, family history ofspeech and language impairment, lowparental educational level, andperinatal risk factors (eg, prematurity,low birth weight, and birthdifficulties).9

Screening Tests

The USPSTF found inadequateevidence on specific screening testsfor use in primary care. Widely usedscreening tests in the United Statesinclude the ASQ, the LanguageDevelopment Survey (LDS), and theMacArthur-Bates CommunicativeDevelopment Inventory (CDI).

Interventions

Interventions for childhood speechand language disorders vary widelyand can include speech-languagetherapy sessions and assistivetechnology (if indicated).

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Interventions are commonlyindividualized to each child’s specificpattern of symptoms, needs, interests,personality, and learning style.Treatment plans also incorporate thepriorities of the child, parents, and/orteachers. Speech-language therapymay take place in various settings,such as speech and language specialtyclinics, the school or classroom, andthe home. Therapy may beadministered on an individual basisand/or in groups, and may be child-centered and/or include peer andfamily components. Therapists maybe speech-language pathologists,educators, or parents. The durationand intensity of the interventiondepend on the severity of the speechor language disorder and the child’sprogress in meeting therapy goals.

Other Approaches to Prevention

The USPSTF recommends screeningfor hearing loss in all newborn infants(B recommendation). The USPSTF isdeveloping a recommendation onscreening for autism spectrumdisorder in young children. Theserecommendations are available onthe USPSTF Web site (www.uspreventiveservicestaskforce.org).

Useful Resources

All states have designated programsthat offer evaluation and interventionservices to children ages 0 to 5 years.IDEA is a law that ensures earlyintervention, special education, andrelated services for children withdisabilities in the United States.Infants and toddlers (birth to age2 years) with disabilities and theirfamilies may receive earlyintervention services under IDEA partC, whereas children and adolescents(ages 3–21 years) may receive specialeducation and related services underIDEA part B.10

OTHER CONSIDERATIONS

Research Needs and Gaps

The USPSTF identified severalevidence gaps, including a critical

need for studies specifically designedand executed to address whethersystematic, routine screening forspeech and language delay anddisorders in young children inprimary care settings leads toimproved speech, language, or otheroutcomes. Studies on the feasibility ofspeech- and language-specificscreening as part of routinedevelopmental screening and thatidentify the most effective screeninginstruments are needed. Studies onthe potential harms of screening andinterventions are also needed.

Information about the prevalence ofspeech and language delays anddisorders in young children in theUnited States is lacking. Moreinformation about the specific factorsassociated with interventioneffectiveness, including the potentialeffects of age at diagnosis, age attreatment, treatment type, andtreatment duration, is needed.

DISCUSSION

Burden of Disease

According to the American Speech-Language-Hearing Association,speech sound disorders affect 10% ofchildren. The estimated prevalence oflanguage difficulty in preschool-agedchildren is between 2% and 19%.Specific language impairment is oneof the most common childhooddisorders, affecting 7% of children.More than 2 million Americansstutter, half of whom are children.11

Childhood speech and languagedisorders include a broad set ofdisorders with heterogeneousoutcomes. Young children withspeech and language delay may beat increased risk of learningdisabilities once they reach schoolage.4 Children with speech sounddisorders or language impairment areat greatest risk of being diagnosedwith a literacy disability,12 includingdifficulty with reading in gradeschool13–16 and/or with writtenlanguage.17

The risk of poor outcomes isgreater for children whosedisorders persist past the earlychildhood years and for those whohave lower IQ scores and languageimpairments rather than onlyspeech impairments.18 Children whoare diagnosed with language delaysmay have more problems withbehavior and psychosocialadjustment, which may persist intoadulthood.19,20

Scope of Review

To update its 2006 recommendationstatement, the USPSTF commissioneda systematic evidence review onscreening for speech and languagedelay and disorders in children aged5 years or younger. The USPSTFreviewed the evidence on theaccuracy of screening in primary caresettings, as well as the role ofsurveillance (active monitoring) byprimary care clinicians to identifychildren for further diagnosticevaluation and interventions forspeech and language delays anddisorders. The USPSTF also evaluatedevidence on whether screening andinterventions for speech andlanguage delay and disorders lead toimproved speech, language, or otheroutcomes, as well as the potentialharms associated with screening andinterventions.

The evidence review focused onspeech and language delays anddisorders with a “primary” ordevelopmental etiology. That is, thereview was limited to studies inchildren who had not been previouslyidentified with another disorder ordisability that may cause speech orlanguage impairment. The reviewexcluded studies that focused onacquired, focal causes of speech andlanguage delay. Although abnormalspeech and language developmentmay be associated with autismspectrum disorder, this review didnot evaluate screening for autismspectrum disorder. The USPSTF iscurrently reviewing the evidence onscreening for autism spectrum

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disorder for a separaterecommendation statement.

The evidence review focused onstudies conducted in children aged5 years or younger in which any childwho screened positive receivedformal diagnostic assessment forspeech and language delays anddisorders by 6 years of age. Studies oftreatment and/or interventionoutcomes were not restricted by ageat treatment but focused primarily ontoddlers and preschool-aged children.

The evidence review includedrandomized controlled trials andother systematic reviews, as well ascohort studies of screening andsurveillance for speech and languagedelays and disorders. The USPSTFfocused on screening instrumentsspecific to speech and languageconditions, as well as more generaldevelopmental screening tools withspeech and language components. Alltools needed to be feasible for use inprimary care or the results had to beinterpretable within a primary caresetting. For surveillance studies, theUSPSTF considered processes ofmonitoring speech and language inprimary care settings rather thanformal screening instruments.Screening and surveillance studieshad to be conducted or results had tobe interpretable in primary caresettings. In contrast, treatmentstudies were not limited by studysetting, which included speech andlanguage clinics, schools, and/orhome settings.

The current review differedsomewhat from the previous reviewin that it focused on screening toolsthat can be administered within theusual length of a primary care visit(#10 minutes) or those that require.10 minutes and are administeredoutside of a primary care setting, ifthe results can be readily interpretedby a primary care clinician. Thecurrent review also focused onstudies in patients without knowncauses of speech and language delay(because these are the patients most

likely to be identified throughscreening).

Accuracy of Screening Tests

The USPSTF identified 24 studies(5 good- and 19 fair-quality)9 thatevaluated the accuracy of 20 differentscreening tools. The majority ofstudies included 2- and 3-year-olds,but the ages varied. Recruitmenttechniques and venues includedadvertisements, birth registries, earlychildhood programs, universityresearch programs, medical practices,and school registration and entrancemedical examinations.

The USPSTF considered 7 parent-administered screening tools: theASQ, the General Language Screen(formerly known as the ParentLanguage Checklist), the Infant-Toddler Checklist, the LDS, the CDI,the Speech and Language ParentQuestionnaire, and the Ward InfantLanguage Screening Test,Assessment, Acceleration, andRemediation. The USPSTF considered13 screening tools administered byprofessionals or paraprofessionals:the Battelle Developmental Inventory,the BRIGANCE Preschool Screen, theDavis Observation Checklist forTexas, the Denver ArticulationScreening Exam, DENVER II (formerlythe Denver Developmental ScreeningTest), a standard developmentalscreen administered by nurses, EarlyScreening Profiles, the FluhartyPreschool Speech and LanguageScreening Test, the NorthwesternSyntax Screening Test, the ScreeningKit of Language Development, theSentence Repetition Screening Test,the Structured Screening Test(formerly known as the HackneyEarly Language Screening Test), andRigby’s trial speech screening test.

Test performance characteristicsvaried widely. Parent-administeredscreening tools generally performedbetter than other tools. Amongparent-administered tools, sensitivitywas generally higher for the CDI, theInfant-Toddler Checklist, and the LDS.

Specificity was comparable across theCDI, the LDS, and the ASQ.

The applicability of the evidence toscreening in primary care is limitedby several factors. Most studiesfocused on prescreened populationswith a relatively high prevalence oflanguage delays and disabilities(usually .10%). The USPSTF found itdifficult to compare the performanceof individual screening tools acrosspopulations because individualstudies used different tools andoutcome measures in differentpopulations and settings. Includedstudies used well-regardedinstruments used by speech-languagepathologists as reference standards;however, individual studies useddifferent reference standards. Inaddition to small sample sizes, somestudies were conducted in countrieswith health care systems that are notcomparable with that of the UnitedStates.

The USPSTF identified no studies onthe accuracy of surveillance of speechand language development byprimary care clinicians.

Effectiveness of Early Detection andInterventions

The review for the USPSTF identified1 poor-quality randomized controlledtrial of screening for language delaysin children ages 18 and 24 monthsthat followed outcomes at ages 3 and8 years.21 This cluster-randomizedtrial and follow-up study wasconducted in 9419 children at 55child health centers in 6 geographicregions of The Netherlands. Outcomesincluded the percentage of childrenwho attended a special school,percentage who repeated a classbecause of language problems, andpercentage who scored low onstandardized language tests. Theauthors concluded that screeningtoddlers for language delay reducesrequirements for special educationand leads to improved languageperformance at age 8 years. However,the study was rated as poor quality,

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and therefore not included in theUSPSTF’s deliberation, because ofseveral limitations, including thefollowing: suboptimal rates ofscreening and low retention of trialsubjects, reliance on indirectmeasures of speech and languageoutcomes in school-aged children(instead of individualized testing),lack of blinding to screening ortreatment status by teachers andparents who assessed outcomes, andlack of adjustment for other potentialreasons for placement in specialeducation.

The USPSTF identified 13 fair- orgood-quality studies on the potentialbenefits of treatment interventionsfor children diagnosed with specificspeech and language delays anddisorders that reported inconsistentfindings on speech and languageoutcomes.9 The majority of the trialsreported improvements in speechand language measures. However, theapplicability of this evidence toroutine screening in a primary caresetting is limited, because many of thestudies were conducted in very highrisk populations (ie, high-prevalencepopulations). In addition, thesestudies did not report treatmenteffectiveness in children whosespeech and language delay hadactually been detected by screening;instead, the delays had often beenidentified as a result of parent orteacher concerns. A majority of theintervention studies were conductedoutside of the United States, whichcould also limit the applicability offindings.

The USPSTF identified 4 fair- or good-quality studies that reportedinconsistent findings on otheroutcomes, including socialization,reading comprehension, parentalstress, and child well-being orattention level.

Potential Harms of Screening andInterventions

The USPSTF identified no studies onthe potential harms of screening in

primary care settings for speech andlanguage delays and disorders, suchas labeling or anxiety. The USPSTFidentified 2 studies (1 fair-quality and1 good-quality) on the potentialharms of treatment that reportedinconsistent findings.9 The treatmentgroup of 1 study reported reducedparental stress, whereas anotherstudy reported no effect on childwell-being or attention level.Treatment harms were generally notmeasured or reported; the 2 includedstudies reported few data on a limitednumber of outcomes.

Estimate of Magnitude of Net Benefit

The USPSTF found inadequateevidence on the accuracy of screeningor surveillance for speech andlanguage delay and disorders inprimary care settings. The USPSTFfound inadequate evidence on thepotential benefits of screening inprimary care settings and treatmenton speech, language, or otheroutcomes. The USPSTF foundadequate evidence that treatment isassociated with improvements insome speech and language measures,but inadequate evidence on itseffectiveness in screen-detectedchildren. The USPSTF foundinadequate evidence on theassociation between treatment andoutcomes other than speech andlanguage. The USPSTF foundinadequate evidence on the potentialharms of screening in primary caresettings and treatment of speech andlanguage delay and disorders.Therefore, the USPSTF concludes thatthe evidence is insufficient and thatthe balance of benefits and harms ofscreening in primary care settings forspeech and language delays anddisorders in young children cannot bedetermined.

Response to Public Comment

A draft version of thisrecommendation statement wasposted on the USPSTF Web site fromNovember 18 to December 15, 2014.In response to public comment, the

USPSTF clarified that thisrecommendation applies only toasymptomatic children whoseparents or clinicians do not havespecific concerns about their speech,language, hearing, or development.The USPSTF also emphasized that thisrecommendation applies only toscreening in primary care settings,and it noted the distinction betweenscreening in primary care settingsand diagnostic testing, which mayoccur in other settings. The USPSTFalso noted that this recommendationdoes not evaluate screening forautism spectrum disorder, which theTask Force will address in a separaterecommendation statement. TheUSPSTF also called for research onsocioeconomic and other factorsassociated with risks, assessment,and management of speech andlanguage delay and disorders inchildren.

UPDATE OF PREVIOUS USPSTFRECOMMENDATION

This recommendation replaces the2006 USPSTF recommendation onscreening for speech and languagedelay in preschool-aged children. Thecurrent recommendation is consistentwith the previous recommendation,which concluded that the evidence onthe routine use of brief, formalscreening instruments in primarycare settings to detect speech andlanguage delay in children aged5 years or younger is insufficient.

RECOMMENDATIONS OF OTHERS

The American Academy ofPediatrics22 recommends thatdevelopmental surveillance beincorporated at every well-childpreventive care visit for children frombirth through age 3 years. It alsorecommends that any concerns raisedduring surveillance should bepromptly addressed withstandardized developmentalscreening tests. In addition, itrecommends that screening testsshould be administered regularly at

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well-child visits at the ages of 9, 18,and 24 or 30 months.

MEMBERS OF THE USPSTF

Members of the USPSTF at the timethis recommendation was finalized*are as follows: Albert L. Siu, MD,MSPH, Chair (Mount Sinai School ofMedicine, New York, and James J.Peters Veterans Affairs MedicalCenter, Bronx, NY); Kirsten Bibbins-Domingo, PhD, MD, MAS, Co-ViceChair (University of California, SanFrancisco, San Francisco, CA); DavidGrossman, MD, MPH, Co-Vice Chair(Group Health, Seattle, WA); LindaCiofu Baumann, PhD, RN, APRN(University of Wisconsin, Madison,WI); Karina W. Davidson, PhD, MASc(Columbia University, New York, NY);Mark Ebell, MD, MS (University ofGeorgia, Athens, GA); Francisco A.R.García, MD, MPH (Pima CountyDepartment of Health, Tucson, AZ);Matthew Gillman, MD, SM (HarvardMedical School and Harvard PilgrimHealth Care Institute, Boston, MA);Jessica Herzstein, MD, MPH(Independent Consultant,Washington, DC); Alex R. Kemper, MD,MPH, MS (Duke University, Durham,NC); Alexander H. Krist, MD, MPH(Fairfax Family Practice, Fairfax, andVirginia Commonwealth University,Richmond, VA); Ann E. Kurth, PhD,RN, MSN, MPH (New York University,New York, NY); Douglas K. Owens,MD, MS (Veterans Affairs Palo AltoHealth Care System, Palo Alto, andStanford University, Stanford, CA);William R. Phillips, MD, MPH(University of Washington, Seattle,WA); Maureen G. Phipps, MD, MPH(Brown University, Providence, RI);and Michael P. Pignone, MD, MPH(University of North Carolina, ChapelHill, NC). Former USPSTF membersMichael L. LeFevre, MD, MSPH, andVirginia Moyer, MD, also contributedto the development of thisrecommendation.

ABBREVIATIONS

ASQ: Ages and StagesQuestionnaire

CDI: MacArthur-BatesCommunicative DevelopmentInventory

IDEA: Individuals With DisabilitiesEducation Act

LDS: Language DevelopmentSurvey

USPSTF: US Preventive ServicesTask Force

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DOI: 10.1542/peds.2015-1711 originally published online July 7, 2015; 2015;136;e474Pediatrics 

Albert L. SiuStatement

Years or Younger: US Preventive Services Task Force Recommendation Screening for Speech and Language Delay and Disorders in Children Aged 5

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Albert L. SiuStatement

Years or Younger: US Preventive Services Task Force Recommendation Screening for Speech and Language Delay and Disorders in Children Aged 5

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