Evidence-based answers from the Family Physicians Inquiries Network

Jo Jackson, MD; Rachel Kornrich, MD How should you evaluate University of Washington, Seattle a toddler for delay? Sarah Safranek, MLIS Health Sciences Library, University of EVIDENCE-BASED ANSWER Washington, Seattle use a brief screening tool to [SOR]: C, expert opinion). ASSISTANT EDITOR A assess children for speech and lan- Speech and therapy im- Gary Kelsberg, MD Valley Family Medicine, guage delay at every preventive visit. If a proves phonological delays and vocabulary Renton, Wash delay in speech is identifi ed, evaluate the diffi culties in young children (SOR: A, sys- child for potentially treatable causes, start- tematic review of randomized controlled ing with a history and physical examination trials [RCTs]). However, no studies have and a formal audiogram. Additional tests evaluated long-term outcomes or looked and referral to appropriate specialists may for adverse eff ects from speech and lan- be indicated (strength of recommendation guage screening or interventions.

Evidence summary and environmental aspects aff ecting speech. Although no studies identify the optimal age A comprehensive physical examination or frequency of screening,1 the American should evaluate the child’s interaction with Academy of Pediatrics (AAP) recommends the examiner and family members, pronun- surveillance for developmental delays (in- ciation of sounds and words, and include a cluding speech and [SLD]) at careful examination of the face, external ears every preventive visit and additional develop- and tympanic membranes, nose, palate, teeth, mental screening at 9, 18, 24, and 30 months.2 tongue, and neck.3,4 No single standardized tool exists to Experts recommend full audiologic as- screen for SLDs; no research compares the sessment and vision testing for all children tools against each other or off ers clear evidence with SLD and an electroencephalogram or of how sensitive they are.1 Commonly used chromosomal studies if appropriate. When brief screening tools include Ages and Stages no cause for the SLD is found, experts recom- Parent Questionnaire (ASQ) (1-66 months mend consulting a speech pathologist. Con- of age), Denver Developmental Screen II sultation with an audiologist, psychologist, (1-66 months), Early Language Milestone neurologist, occupational therapist, or social Scale (1-36 months), Clinical Adaptive Test/ worker also may be helpful.1-4 Clinical Linguistic and Auditory Milestone Scale (<24 months), Infant Developmental How effective are speech Inventory and Review and language interventions? (1-66 months), and the Fluharty Preschool A systematic review of 14 RCTs evaluated Speech and Language Screening Tests speech and language therapy interventions (3-5 years). ranging from 3 to 6 months’ duration in pre- school children. Investigators reported signifi - When a child screens positive cant improvements in speech and language for speech and language delay outcomes, including articulation, phonation When an SLD is recognized, experts recom- and syntax, and expressive and receptive lan- mend a history and physical examination to guage with the interventions. Individual stud- evaluate for common causes (TABLE). A de- ies were limited by small size, heterogeneity, tailed history should focus on family, social, and varied measures of short-term outcomes.1

230 THE JOURNAL OF FAMILY PRACTICE | APRIL 2011 | VOL 60, NO 4 TABLE Common causes of speech and language delays

Autism Bilingualism Cerebral palsy Elective mutism Expressive language disorder (developmental expressive aphasia) Hearing loss Maturation delay (developmental language delay) Mental retardation Psychosocial deprivation Receptive aphasia

Source: Leung A, et al. Am Fam Physician. 1999.4

A Cochrane meta-analysis of 25 RCTs Recommendations (N=1539 children, of whom 986 were <5 years) Th e AAP Council on Children with Dis- found that speech and language therapy pro- abilities, Section on Developmental Be- duced similar improvements for preschool and havioral Pediatrics recommends general elementary school children. Th erapy improved developmental surveillance at every well- Use a brief phonological delays signifi cantly (standard child visit for children from birth through 3 screening tool mean diff erence [SMD]=0.44; 95% confi dence years of age and more formal screening tests to assess interval [CI], 0.01-0.86), and vocabulary dif- at the 9-, 18-, and 30-month visits. Th e AAP children for fi culties even more (SMD=0.89; 95% CI, 0.21- doesn’t recommend a specifi c screening test, speech and 1.56). However, in this review, therapy didn’t however.2 language signifi cantly aff ect receptive speech diffi culties Th e US Preventive Services Task Force delay at every (SMD=−0.04; 95% CI, −0.64 to 0.56). found insuffi cient evidence that brief formal preventive visit. Th e analysis didn’t evaluate whether screening instruments accurately identify pre- specifi c age groups would respond better to school children who would benefi t from fur- therapy.5 No studies evaluated long-term ef- ther evaluation and intervention, but found fectiveness or possible harms associated with fair evidence that interventions improve screening or intervention.4 speech in the short term.6 JFP

References 1. Nelson HD, Nygren P, Walker M, et al. Screening for speech 3. Feldman HM. Evaluation and management of language and speech and language delay in preschool children: systematic evidence disorders in preschool children. Pediatr Rev. 2005;26:131-142. review for the US Preventive Services Task Force. Pediatrics. 4. Leung A, Kao CP. Evaluation and management of the child with 2006;117:e298-e319. speech delay. Am Fam Physician. 1999;59:3121-3128, 3135. 2. Council on Children with Disabilities, Section on Developmen- 5. Law J, Garrett Z, Nye C. Speech and language therapy interven- tal Behavioral Pediatrics; Bright Futures Steering Committee; tions for children with primary speech and language delay or Medical Home Initiatives for Children with Special Needs Proj- disorder. Cochrane Database Syst Rev. 2003;(3):CD004110. ect Advisory Committee. Identifying infants and young children with developmental disorders in the medical home: an algo- 6. US Preventive Services Task Force. Screening for speech and lan- rithm for developmental surveillance and screening. Pediatrics. guage delay in preschool children: recommendation statement. 2006;118:405-420. Pediatrics. 2006;117:497-501.

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