Final Research Plan

Speech and Language Delay and Disorders in Children Age 5 and Younger: Screening

November 15, 2013

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.

The final Research Plan is used to guide a systematic review of the evidence by researchers at an Evidence-based Practice Center. The resulting Evidence Report forms the basis of the USPSTF Recommendation Statement on this topic.

The draft Research Plan was available for comment from July 25 until August 21, 2013 at 5:00 p.m., ET. 

Select Text Description below for details.

a Excluding children with diagnosed disorders including autism, mental retardation, Fragile X, hearing loss, degenerative and other neurologic conditions.
b School performance, behavioral competence, socioemotional development, quality of life, and others.

Text Description

This figure is an analytic framework depicting the key questions (KQs) relevant to screening and interventions for speech and language delay and disorders in children age 5 years or younger. The figure illustrates the relationship between screening, surveillance, referral, diagnosis, and intervention for speech and language delay. KQ 1 concerns the relationship between screening and the ultimate outcomes of interest: improved speech and language outcomes and improved nonspeech and language outcomes. The population is shown as either failing or passing screening. Children who pass screening may receive surveillance at future nonscreening visits (KQ 4). Among children who fail screening, the path either leads to referral to a diagnostic evaluation (KQ 2) or enhanced surveillance (KQ 4). Based on the diagnostic evaluation, the framework depicts a path to either the endpoint of no delay or disorder detected or to an intervention for the speech or language delay or disorder. Interventions result in either improved speech and language (KQ 5) or improved nonspeech and language skills (KQ 6). Adverse effects of screening (KQ 3) and interventions (KQ 7) are also shown


  1. Does screening for speech and language delay or disorders lead to improved speech and language outcomes, as well as improved outcomes in domains other than speech and language?
  2. Do screening evaluations in the primary care setting accurately identify children for diagnostic evaluations and interventions?
    1. What is the accuracy of these screening techniques and does it vary by age, cultural/linguistic background, whether it is conducted in a child's native language, or by how the screening was administered (i.e., parent report, parent interview, direct assessment of child by professional)?
    2. What are the optimal ages and frequency for screening?
    3. Is selective screening based on risk factors more effective than unselected, general population screening?
    4. Does the accuracy of selective screening vary based on risk factors? Is the accuracy of screening different for children with an inherent language disorder compared with children whose language delay is due to environmental factors?
  3. What are the adverse effects of screening for speech and language delay or disorders?
  4. Does surveillance (active monitoring) by primary care clinicians play a role in accurately identifying children for diagnostic evaluations and interventions?
  5. Do interventions for speech and language delay or disorders improve speech and language outcomes?
  6. Do interventions for speech and language delay or disorders improve other outcomes, such as academic achievement, behavioral competence, and socioemotional development or health outcomes, such as quality of life?
  7. What are the adverse effects of interventions for speech and language delay or disorders (e.g., time, stress, and stigma)?

Contextual questions will not be systematically reviewed and are not shown in the Analytic Framework.

  1. What are the techniques for screening for speech and language delay or disorders and do they differ by age and cultural background?
  2. What risk factors are associated with speech and language delay?
  3. What is the role of primary care providers in screening in children age 5 years or younger that is performed in other venues (such as Head Start or preschool)?

The Research Approach identifies the study characteristics and criteria that the Evidence-based Practice Center will use to search for publications and to determine whether identified studies should be included or excluded from the Evidence Report. Criteria are overarching as well as specific to each of the key questions (KQs).

Category Include Exclude
Populations Children age 5 years or younger (for screening) who speak any language Children with previously known conditions associated with language delay (e.g., hearing impairment, developmental or neurological/neurogenetic impairment)
Setting Studies conducted in countries listed as “high” on the Human Development Index Studies conducted in countries not listed as “high” on the Human Development Index
Screening All instruments and procedures that are applicable for use in children age 5 years or younger:
  • ≤10 minutes to administer or to be interpreted in a primary care setting
  • >10 minutes if completed by a parent or teacher and interpreted by the clinician
  • Instruments specifically for speech and language
  • General developmental instruments with a separate component for speech and/or language skills
  • Instruments not designed for use in children age 5 years or younger
  • Tools that take >10 minutes to administer
  • General developmental screening instruments that do not have a separate component for speech and/or language skills

Treatment/management interventions

  • All standardized and nonstandardized procedures to diagnose specific speech and/or language impairments that are appropriate for use in children younger than age 6 years
  • All therapeutic interventions designed to improve speech or language in children, as long as diagnosis occurs when child is age 6 years or younger
    • Therapists may be speech-language pathologists or other clinicians, parents, or teachers
    • Therapeutic settings include group and individual sessions offered in a clinical locale, school, or home
  • Diagnostic procedures administered to children older than age 6 years
  • Therapeutic interventions delivered to children who are diagnosed after age 6 years
Comparisons KQs 1, 3: Screened vs. unscreened
KQs 2, 4: Different subpopulations (e.g., by age, risk factors)
KQ 4: Surveillance vs. referral for diagnosis
KQs 5–7: Intervention vs. no intervention; length of time until outcome measurement
  • Single-group design with no comparator
  • Treatment comparisons
  • Improvements in all aspects of speech and/or language functioning:
    • Speech domains include stuttering, fluency, and articulation
    • Language domains include expressive language, receptive language, phonology, vocabulary, syntax, and/or pragmatics
  • Improvements in other types of functioning, such as emergent academic skills, academic achievement (e.g., reading, writing, spelling, arithmetic), behavior competence, socioemotional functioning, quality of life, and parental satisfaction
Study Design KQs 1–4, 7: Cohort studies; randomized, controlled trials; systematic reviews
KQs 5, 6: Randomized, controlled trials or systematic reviews of randomized, controlled trials
  • Letters to the editor that do not present primary data, commentaries, editorials, case reports, or case series
  • Poor-quality studies (studies with poor internal or external validity)
Language English Languages other than English


The draft Research Plan was posted for public comment on the U.S. Preventive Services Task Force (USPSTF) Web site from July 25 to August 21, 2013. In response to comments, several key questions were expanded to include more detail; the USPSTF added several child and test characteristics that may affect screening, as well as several specific possible adverse effects of interventions. The USPSTF revised the analytic framework to reflect that referral and diagnostic evaluations for a speech and language delay or disorder could lead to the identification of nonspeech and language diagnostic concerns. This outcome acknowledges that speech and language screening and evaluation can be the gateway to the diagnosis of other conditions, such as autism spectrum disorder. As the framework shows, the review will not examine outcomes related to the diagnosis of other conditions. The USPSTF also added a loop in the analytic framework, from no disorder or delay detected during the diagnostic evaluation back to surveillance, to indicate that screening/surveillance can be a recurrent process.