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 Index¹³ 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 Exam²² and the articulation portion of both the Fluharty Preschool Speech and Language Screening Test (FPSLST)³⁷ and the SRST³⁸—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 FPST²⁰ 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?

No eligible study addressed this question.

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 trials⁵⁰ and 11 weekly 2.5-hour sessions plus 3 weekly home visits in the other trial⁵¹), 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 setting⁵⁴ 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?

No eligible study addressed this question.

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.

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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 al²³ 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.