Speech and Language Delay and Disorders in Children: Screening

The US Preventive Services Task Force (USPSTF) makes recommendations about the effectiveness of specific preventive care services for patients without obvious related signs or symptoms to improve the health of people nationwide. 

It bases its recommendations on the evidence of both the benefits and harms of the service and an assessment of the balance. The USPSTF does not consider the costs of providing a service in this assessment. 

The USPSTF recognizes that clinical decisions involve more considerations than evidence alone. Clinicians should understand the evidence but individualize decision-making to the specific patient or situation. Similarly, the USPSTF notes that policy and coverage decisions involve considerations in addition to the evidence of clinical benefits and harms.

The USPSTF is committed to mitigating the health inequities that prevent many people from fully benefiting from preventive services. Systemic or structural racism results in policies and practices, including health care delivery, that can lead to inequities in health. The USPSTF recognizes that race, ethnicity, and gender are all social rather than biological constructs. However, they are also often important predictors of health risk. The USPSTF is committed to helping reverse the negative impacts of systemic and structural racism, gender-based discrimination, bias, and other sources of health inequities, and their effects on health, throughout its work.

Speech and language delays and disorders can pose significant problems for children and their families. Evidence suggests that school-age children with speech or language delays may be at increased risk of learning and literacy disabilities, including difficulties with reading and writing.^1-3 Observational cohort studies suggest that children with these conditions may also be at higher risk for social and behavioral problems in addition to learning problems, some of which may persist through adulthood.^4,5 Research is needed to determine whether identifying speech and language delays early and providing interventions helps prevent these issues before they interfere with school learning or psychosocial adjustment.

The USPSTF concludes that the evidence is insufficient to assess the balance of benefits and harms of screening for speech and language delay and disorders in children. More research is needed.

See Table 1 for more information on the USPSTF recommendation rationale and assessment. For more details on the methods the USPSTF uses to determine the net benefit, see the USPSTF Procedure Manual.⁶

Patient Population Under Consideration

This statement applies only to asymptomatic children age 5 years or younger whose parents or clinicians do not have specific concerns about their speech, language, hearing, or development.

The focus of this statement is identifying and treating “primary” speech and language delays and disorders (i.e., in children who have not been previously identified with another disorder or disability that may cause speech or language impairment).

Definitions

Speech or language delay refers to children who are developing speech and language in the correct sequence but at a slower rate than expected.⁷ There is no universally accepted threshold for delay in speech or language development; however, performance on a standardized assessment that falls at least one standard deviation below the mean is often considered a delay.⁷

Speech or language disorders refer to speech or language ability that is qualitatively different from typical development. Speech disorders are defined by difficulty with forming specific sounds or words correctly (articulation) or making words or sentences flow smoothly (fluency). Language disorders are characterized by difficulty understanding (receptive language) or speaking (expressive language) relative to a child’s peers.⁸

Screening Tests

There are several screening tools used in primary care settings to detect speech and language delay and disorders. Some tools are part of a larger instrument designed to assess general development that includes multiple questions specific to speech and language (e.g., Ages & Stages Questionnaires, Third Edition [ASQ-3]).⁷ Other tools are designed to assess only speech and language development. Most screening instruments are unable to discern the difference between a child who has a delay (i.e., a child with late-emerging language during the first 2 years of life) that subsequently resolves without treatment and one who will go on to display a speech and language disorder (i.e., a child who will later receive a formal diagnosis of specific language impairment).⁷

Treatment or Interventions

Interventions for childhood speech and language disorders vary widely and can include speech-language therapy sessions and assistive technology.^9,10 Interventions are commonly individualized to each child’s specific pattern of symptoms, needs, interests, personality, and learning style.⁷ Treatment plans also incorporate the priorities of the child, parents, teachers, or some combination thereof. Speech-language therapy may take place in various settings, such as speech and language specialty clinics, the school or classroom, the home, and via telehealth.¹¹ Therapy may be administered on an individual basis or in groups and may be child-centered or include peer and family components. Therapists may be speech-language pathologists, educators, or parents. The duration and intensity of the intervention usually depend on the severity of the speech or language disorder and the child’s progress in meeting therapy goals.⁷

Suggestions for Practice Regarding the I Statement

Potential Preventable Burden

Information about the prevalence of speech and language delays and disorders in young children in the United States is limited and varies by age and other factors. In a 2016 report, the National Academy of Sciences estimated that the prevalence of speech and language disorders ranges between 3% and 16% of U.S. children ages 3 to 18 years.¹²

Several risk factors have been reported to be associated with speech and language delay and disorders, including male sex, family history of speech and language impairment, low parental education level, and perinatal risk factors (e.g., prematurity, low birth weight, and birth difficulties).¹³

Multiple studies have demonstrated a higher prevalence among boys than girls and among certain groups defined by race and ethnicity. A 2012 survey found that nearly 8% of children ages 3 to 17 years had a communication disorder (speech and language disorder), with boys almost twice as likely to be affected than girls. In the same study, approximately 10% of non-Hispanic Black children were affected compared with 7.8% and 6.9% of children identified as White or Hispanic, respectively.¹⁴ Disparities in the prevalence of speech and language delay and disorders have also been observed based on various measures of socioeconomic status, including type of insurance. For example, a nationally representative U.S. cohort study found that by age 8 years, the prevalence of speech or language disorders was significantly higher among publicly insured children than privately insured children (8.4% vs. 4.5%, respectively).¹⁵

Many children identified as toddlers with speech and language delays go on to recover without intervention. One systematic review estimated that approximately 60% of children with expressive language delay and 25% with receptive and expressive delay recovered without intervention.¹⁶ However, evidence also suggests that school-age children with speech or language delays may be at increased risk of learning and literacy disabilities, including difficulties with reading and writing.^1-3 Observational cohort studies suggest that children with these conditions may also be at higher risk for social and behavioral problems in addition to learning problems, some of which may persist through adulthood.^17,4,5

Potential Harms

The potential harms of screening and interventions for speech and language delays and disorders in young children in primary care include the time, effort, and anxiety associated with further testing after a positive screening result, as well as the potential harms associated with diagnostic labeling.¹⁸ The USPSTF found no studies on these harms.⁷

Current Practice

Surveillance and screening for speech and language delay and disorders is commonly performed as part of routine developmental surveillance and screening in primary care settings (i.e., during well-child visits).² An estimated 30% of U.S. children ages 9 to 35 months received a parent-completed developmental screening in the past year, with significant variation across states (ranging from 17% in Mississippi to 59% in Oregon).¹⁹ General screening instruments with speech and language components (e.g., ASQ) are the most used tools.²⁰ It is unclear how many clinicians use tools specific to speech and language development.⁷

Implementation of screening and treatment protocols remain a challenge. Based on data from the 2012 National Health Interview Survey, approximately half of all children ages 3 to 17 years with a speech and language disorder received an intervention service in the previous 12 months.¹⁴ Additionally, disparities exist in the rates of referral or services by race and ethnicity for children who are identified as having a potential speech or language problem. Children identified as Hispanic/Latino and Black are less likely to receive services compared with children identified as White.¹⁴

Other Related USPSTF Recommendations

The USPSTF has a separate recommendation statement on screening for autism spectrum disorder (I statement).²¹

In 2015, the 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 age 5 years or younger (I statement).¹⁸ This recommendation concurs with the previous I statement.

Scope of Review

The USPSTF commissioned a systematic review to evaluate the benefits and harms of screening for speech and language delay and disorders in children age 5 years or younger. It also evaluated evidence on whether interventions for screen-detected speech and language delay and disorders lead to improved speech, language, or other outcomes, as well as the potential harms associated with screening and interventions. Treatment studies enrolling children up to age 6 years were eligible given that children who would be screened at age 5 years and referred for treatment may not receive services immediately.⁷

The review was limited to studies in children who had not been previously identified with another disorder or disability that may cause speech or language impairment. The review excluded studies that focused on acquired, focal causes of speech and language delay. Although abnormal speech and language development may be associated with autism spectrum disorder, this review did not evaluate screening for autism spectrum disorder. The USPSTF has a separate recommendation statement on screening for autism spectrum disorder.²¹

Accuracy of Screening Tests

The USPSTF identified 21 good- or fair-quality studies (n=7,489) that evaluated the accuracy of 23 screening tools for detecting speech and language delays and disorders in young children.⁷ The age of study populations ranged from 12 to 70 months (approximately 5.80 years), with a mean age of 39 months. Recruitment techniques and venues included primary care practices, childcare centers/preschools/kindergartens, health/public health centers, advertisements, birth announcements, early childhood programs, and Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) offices. In the 16 studies that reported the sex of the participants, 47% were female. Most studies did not report race and ethnicity. The median prevalence of speech and language disorders in the study populations was 16% (range, 4% to 59%).⁷

Thirteen of the 21 speech and language screening tools were designed to be administered by a trained examiner and 10 were parent reports of speech or language skills. Twelve instruments were designed to screen for global language delay and disorders, nine were designed to screen for specific language problems such as expressive language skills or understanding of syntax, and four instruments were used to screen for articulation problems.

Overall, the median sensitivity and specificity of instruments for detecting speech and language delay and disorders was 87% (range, 43% to 100%) and 88% (range, 32% to 98%), respectively.⁷ Test accuracy varied in terms of whether the instruments were completed by parents vs. trained examiners and whether the instruments focused on global language, specific language skills, or articulation. In general, screening tools designed for use by trained examiners were slightly more accurate than those designed for parent reports. Few screening instruments were assessed by more than one study each, making it difficult to make conclusions about the accuracy of specific questionnaires.⁷

Benefits of Early Detection and Treatment

The USPSTF found no studies addressing the direct benefits of screening for speech and language delay and disorders on health outcomes such as school performance, function, or quality-of-life outcomes.⁷ The USPSTF identified 17 randomized, controlled trials on the potential benefits of interventions for children diagnosed with speech and language delays and disorders.⁷ Study participants were recruited from several different settings, including schools or early childhood education centers (4 studies), referrals to speech and language treatment centers (6 studies), via advertisements (4 studies), and a mix of advertisements and outreach to schools, clinical settings, or community-based programs. The mean age of enrolled populations ranged from 18.1 to 67.8 months (5.6 years), with the majority of studies (10 studies) including a population with a mean age of 48.4 months or older.⁷

The included studies evaluated a diverse array of interventions that targeted different populations of children (e.g., any delay or disorder or speech disorders only) and varied by setting, intensity/duration, and delivery personnel. Eight trials assessed interventions specific to children with language delay and without fluency or speech-sound impairment. Of these, two studies evaluating more intensive parent-delivered, group training interventions found benefits for expressive language outcome measures.⁷ Other interventions for language delay varied by delivery setting, population, and other factors. In general, results were inconsistent, with some studies showing improvement in some measures of receptive or expressive language but others not. Two randomized, controlled trials assessed treatment for young children with fluency disorder (stuttering) delivered by a speech-language pathologist. Both found benefit for reducing stuttering frequency at 9 months postintervention. It was unclear whether these children were identified by formal screening or through normal surveillance.⁷

Eight studies reported on outcomes related to school or academic performance, early literacy, functional communication, or quality of life.⁷ However, no studies of the same intervention reported on similar measures of school performance, behavior, or well-being. Four studies reported measures of early literacy, with only one trial demonstrating statically significant benefit for improving letter knowledge. Two trials assessing different interventions for speech sound disorders found no statistically significant difference between groups on measures of functional communication. No study reported benefit for improving function or quality of life among children.⁷

Harms of Screening and Treatment

The USPSTF identified no studies on the potential harms of screening or interventions for speech and language delay and disorders in children.⁷

See Table 2 for the research needs and gaps related to screening for speech and language delay and disorders in children. 

The American Academy of Pediatrics recommends routine developmental surveillance at all well-child visits and developmental screening (not specific to speech and language delay and disorders) with validated tools at the 9-month, 18-month, and 30-month visits.^22-24 The Canadian Task Force on Preventive Health Care recommends against screening for developmental delay using standardized tools in children ages 1 to 4 years with no apparent signs of developmental delay and whose parents and clinicians have no concerns about development.

To fulfill its mission to improve health by making evidence-based recommendations for preventive services, the USPSTF routinely highlights the most critical evidence gaps for making actionable preventive services recommendations. The USPSTF often needs additional evidence to create the strongest recommendations for everyone and especially for persons with the greatest burden of disease. Table 2 summarizes the key bodies of evidence needed for the USPSTF to make a recommendation for screening for speech and language delay and disorders in children. For each of the evidence gaps listed below, research must focus on screening and preventive interventions that can be performed in, or referred from, the primary care setting.