Screening for and Delay and Disorders in Children Aged 5 Years or Younger: US Preventive Services Task Force Recommendation Statement Albert L. Siu, MD, MSPH, on behalf of the US Preventive Services Task Force

BACKGROUND: This report is an update of the US Preventive Services Task Force abstract (USPSTF) 2006 recommendation on screening for speech and language delay in preschool-aged children. METHODS: The USPSTF reviewed the evidence on screening for speech and language delay and disorders in children aged 5 years or younger, including the accuracy of screening in primary care settings, the role of surveillance by primary care clinicians, whether screening and interventions lead to improved outcomes, and the potential harms associated with screening and interventions. POPULATION: This recommendation applies to asymptomatic children aged Recommendations made by the US Preventive fi Services Task Force are independent of the US 5 years or younger whose parents or clinicians do not have speci c concerns government. They should not be construed as an about their speech, language, hearing, or development. official position of the Agency for Healthcare Research and Quality or the US Department of RECOMMENDATION: The USPSTF concludes that the current evidence is insufficient Health and Human Services. to assess the balance of benefits and harms of screening for speech and www.pediatrics.org/cgi/doi/10.1542/peds.2015-1711 language delay and disorders in children aged 5 years or younger DOI: (I statement). 10.1542/peds.2015-1711 Accepted for publication May 20, 2015 Address correspondence to USPSTF Senior Project TheUSPreventiveServicesTask the USPSTF notes that policy and Coordinator, 540 Gaither Rd, Rockville, MD 20850. Force (USPSTF) makes coverage decisions involve E-mail: [email protected] recommendations about the considerations in addition to the PEDIATRICS (ISSN Numbers: Print, 0031-4005; Online, effectiveness of specificpreventive evidence of clinical benefits and 1098-4275). care services for patients without harms. Copyright © 2015 by the American Academy of related signs or symptoms. Pediatrics FINANCIAL DISCLOSURE: It bases its recommendations on the The author has indicated he has no financial relationships relevant to this article fi evidence of both the bene ts and harms SUMMARY OF RECOMMENDATION AND to disclose. of the service and an assessment of the EVIDENCE FUNDING: The US Preventive Services Task Force balance. The USPSTF does not consider The USPSTF concludes that the current (USPSTF) is an independent, voluntary body. The US the costs of providing a service in this evidence is insufficient to assess the Congress mandates that the Agency for Healthcare Research and Quality support the operations of the assessment. balance of benefits and harms of USPSTF. The USPSTF recognizes that clinical screening for speech and language POTENTIAL CONFLICT OF INTEREST: The author has delay and disorders in children aged decisions involve more considerations indicated he has no potential conflicts of interest to than evidence alone. Clinicians should 5 years or younger (I statement). (See disclose. the Clinical Considerations section for understand the evidence but COMPANION PAPER: A companion to this article can individualize decision-making to the suggestions for practice regarding the be found on page XXX, and online at www.pediatrics. specific patient or situation. Similarly, I statement.) org/cgi/doi/10.1542/peds.2014-3889.

PEDIATRICS Volume 136, number 2, August 2015 SPECIAL ARTICLE RATIONALE Information about the prevalence of Information on the natural history of speech and language delays and speech and language delays and Importance disorders in young children in the disorders, including how outcomes Speech and language delays and United States is limited. In 2007, may change as a result of screening or disorders can pose significant ∼2.6% of children ages 3 to 5 years treatment, is also limited. problems for children and their received services for speech and families. Children with speech and language disabilities under the Detection language delays develop speech or Individuals With Disabilities language in the correct sequence but Education Act (IDEA).2 In 1 The USPSTF found inadequate at a slower rate than expected, population-based study in 8-year- evidence on the accuracy of screening whereas children with speech and olds in Utah, the prevalence of instruments for speech and language language disorders develop speech or children with delay for use in primary care settings. language that is qualitatively different disorders (speech or language) on the Several factors limited the from typical development. basis of special education or applicability of the evidence to Differentiating between delays and International Classification of routine screening in primary care disorders can be complicated. First, Diseases, Ninth Revision, settings. screening instruments have difficulty classifications was 63.4 cases per The USPSTF also found inadequate distinguishing between the 2. Second, 1000 children.3 The prevalence of evidence on the accuracy of although the majority of school-aged isolated communication disorders surveillance (active monitoring) by children with language disorders (ie, children without a concomitant primary care clinicians to identify present with language delays as diagnosis of spectrum children for further evaluation for , some children outgrow their disorder or ) speech and language delays and language delay.1 was 59.1 cases per 1000 children. disorders.

2 SIU Benefits of Early Detection and parents or clinicians do not have recommended as part of routine Intervention specific concerns about their speech, developmental surveillance and The USPSTF found inadequate language, hearing, or development. It screening in primary care settings 5 evidence on the benefits of screening does not apply to children whose (ie, during well- visits). In and early intervention for speech and parents or clinicians raise those practice, however, such screening is language delay and disorders in concerns; these children should not universal. The previous evidence 6 primary care settings. undergo evaluation and, if needed, review found that 55% of parents treatment. reported that their did not The USPSTF found inadequate receive any type of developmental evidence on the effectiveness of This recommendation discusses the fi assessment at their well-child visit, screening in primary care settings for identi cation and treatment of “primary” speech and language delays and 30% of parents reported that speech and language delay and their child’s health care provider had disorders on improving speech, and disorders (ie, in children who have not been previously identified with not discussed with them how their language, or other outcomes. child communicates.7 In a 2009 study, Although the USPSTF found evidence another disorder or disability that may cause speech or language impairment). approximately half of responding that interventions improve some pediatricians reported that they measures of speech and language for Suggestions for Practice Regarding “always or almost always” use some children, there is inadequate the I Statement a standardized screening tool to evidence on the effectiveness of Potential Preventable Burden detect developmental problems in interventions in children detected by young children; ∼40% of respondents screening in a primary care setting. Information about the prevalence of reported using the Ages and Stages The USPSTF found inadequate speech and language delays and Questionnaire (ASQ).8 The USPSTF evidence on the effectiveness of disorders in young children in the distinguishes between screening in interventions for speech and United States is limited. In 2007, primary care settings and diagnostic ∼ language delay and disorders on 2.6% of children ages 3 to 5 years testing, which may occur in other outcomes not specific to speech received services for speech and settings. 2 (eg, academic achievement, behavioral language disabilities under IDEA. competence, socioemotional Childhood speech and language Assessment of Risk development, and quality of life). disorders include a broad set of On the basis of a review of 31 cohort disorders with heterogeneous studies, several risk factors have been Harms of Early Detection and outcomes. Information about the reported to be associated with speech Intervention natural history of these disorders is and language delay and disorders, The USPSTF found inadequate limited, because most affected including male sex, family history of evidence on the harms of screening in children receive at least some type of speech and language impairment, low primary care settings and intervention. However, there is some parental educational level, and interventions for speech and evidence that young children with perinatal risk factors (eg, prematurity, language delay and disorders in speech and language delay may be at low birth weight, and birth children aged 5 years or younger. increased risk of language-based difficulties).9 learning disabilities.4 USPSTF Assessment Screening Tests Potential Harms The USPSTF concludes that the The USPSTF found inadequate evidence is insufficient and that the The potential harms of screening and evidence on specific screening tests balance of benefits and harms of interventions for speech and for use in primary care. Widely used screening and interventions for language disorders in young children screening tests in the United States speech and language delay and in primary care include the time, include the ASQ, the Language disorders in young children in effort, and anxiety associated with Development Survey (LDS), and the primary care settings cannot be further testing after a positive screen, MacArthur-Bates Communicative determined. as well as the potential detriments Development Inventory (CDI). associated with diagnostic labeling. Interventions CLINICAL CONSIDERATIONS However, the USPSTF found no studies on these harms. Interventions for childhood speech Patient Population Under and language disorders vary widely Consideration Current Practice and can include speech-language This recommendation applies only to Surveillance or screening for speech therapy sessions and assistive asymptomatic children whose and language disorders is commonly technology (if indicated).

PEDIATRICS Volume 136, number 2, August 2015 3 Interventions are commonly need for studies specifically designed The risk of poor outcomes is individualized to each child’s specific and executed to address whether greater for children whose pattern of symptoms, needs, interests, systematic, routine screening for disorders persist past the early personality, and learning style. speech and language delay and childhood years and for those who Treatment plans also incorporate the disorders in young children in have lower IQ scores and language priorities of the child, parents, and/or primary care settings leads to impairments rather than only teachers. Speech-language therapy improved speech, language, or other speech impairments.18 Children who may take place in various settings, outcomes. Studies on the feasibility of are diagnosed with language delays such as speech and language specialty speech- and language-specific may have more problems with clinics, the school or classroom, and screening as part of routine behavior and psychosocial the home. Therapy may be developmental screening and that adjustment, which may persist into administered on an individual basis identify the most effective screening adulthood.19,20 and/or in groups, and may be child- instruments are needed. Studies on centered and/or include peer and the potential harms of screening and Scope of Review family components. Therapists may interventions are also needed. To update its 2006 recommendation be speech-language pathologists, Information about the prevalence of statement, the USPSTF commissioned educators, or parents. The duration speech and language delays and a systematic evidence review on and intensity of the intervention disorders in young children in the screening for speech and language depend on the severity of the speech United States is lacking. More delay and disorders in children aged ’ or and the child s information about the specific factors 5 years or younger. The USPSTF progress in meeting therapy goals. associated with intervention reviewed the evidence on the accuracy of screening in primary care Other Approaches to Prevention effectiveness, including the potential effects of age at diagnosis, age at settings, as well as the role of The USPSTF recommends screening treatment, treatment type, and surveillance (active monitoring) by for hearing loss in all newborn infants treatment duration, is needed. primary care clinicians to identify (B recommendation). The USPSTF is children for further diagnostic developing a recommendation on evaluation and interventions for screening for autism spectrum DISCUSSION speech and language delays and disorder in young children. These disorders. The USPSTF also evaluated recommendations are available on Burden of Disease evidence on whether screening and the USPSTF Web site (www. According to the American Speech- interventions for speech and uspreventiveservicestaskforce.org). Language-Hearing Association, language delay and disorders lead to speech sound disorders affect 10% of improved speech, language, or other Useful Resources children. The estimated prevalence of outcomes, as well as the potential All states have designated programs language difficulty in preschool-aged harms associated with screening and that offer evaluation and intervention children is between 2% and 19%. interventions. fi services to children ages 0 to 5 years. Speci c language impairment is one The evidence review focused on IDEA is a law that ensures early of the most common childhood speech and language delays and intervention, special education, and disorders, affecting 7% of children. disorders with a “primary” or related services for children with More than 2 million Americans developmental etiology. That is, the 11 disabilities in the United States. stutter, half of whom are children. review was limited to studies in Infants and toddlers (birth to age Childhood speech and language children who had not been previously 2 years) with disabilities and their disorders include a broad set of identified with another disorder or families may receive early disorders with heterogeneous disability that may cause speech or intervention services under IDEA part outcomes. Young children with language impairment. The review C, whereas children and adolescents speech and language delay may be excluded studies that focused on – (ages 3 21 years) may receive special at increased risk of learning acquired, focal causes of speech and education and related services under disabilities once they reach school language delay. Although abnormal 10 IDEA part B. age.4 Children with speech sound speech and disorders or language impairment are may be associated with autism OTHER CONSIDERATIONS at greatest risk of being diagnosed spectrum disorder, this review did with a literacy disability,12 including not evaluate screening for autism Research Needs and Gaps difficulty with in grade spectrum disorder. The USPSTF is The USPSTF identified several school13–16 and/or with written currently reviewing the evidence on evidence gaps, including a critical language.17 screening for autism spectrum

4 SIU disorder for a separate likely to be identified through Specificity was comparable across the recommendation statement. screening). CDI, the LDS, and the ASQ. The evidence review focused on The applicability of the evidence to studies conducted in children aged Accuracy of Screening Tests screening in primary care is limited 5 years or younger in which any child The USPSTF identified 24 studies by several factors. Most studies who screened positive received (5 good- and 19 fair-quality)9 that focused on prescreened populations formal diagnostic assessment for evaluated the accuracy of 20 different with a relatively high prevalence of speech and language delays and screening tools. The majority of language delays and disabilities . disorders by 6 years of age. Studies of studies included 2- and 3-year-olds, (usually 10%). The USPSTF found it fi treatment and/or intervention but the ages varied. Recruitment dif cult to compare the performance outcomes were not restricted by age techniques and venues included of individual screening tools across at treatment but focused primarily on advertisements, birth registries, early populations because individual toddlers and preschool-aged children. childhood programs, university studies used different tools and outcome measures in different The evidence review included research programs, medical practices, populations and settings. Included randomized controlled trials and and school registration and entrance studies used well-regarded other systematic reviews, as well as medical examinations. instruments used by speech-language cohort studies of screening and The USPSTF considered 7 parent- pathologists as reference standards; surveillance for speech and language administered screening tools: the however, individual studies used delays and disorders. The USPSTF ASQ, the General Language Screen different reference standards. In focused on screening instruments (formerly known as the Parent addition to small sample sizes, some specific to speech and language Language Checklist), the Infant- studies were conducted in countries conditions, as well as more general Toddler Checklist, the LDS, the CDI, with health care systems that are not developmental screening tools with the Speech and Language Parent comparable with that of the United speech and language components. All Questionnaire, and the Ward Infant States. tools needed to be feasible for use in Language Screening Test, fi primary care or the results had to be Assessment, Acceleration, and The USPSTF identi ed no studies on interpretable within a primary care Remediation. The USPSTF considered the accuracy of surveillance of speech setting. For surveillance studies, the 13 screening tools administered by and language development by USPSTF considered processes of professionals or paraprofessionals: primary care clinicians. monitoring speech and language in the Battelle Developmental Inventory, primary care settings rather than the BRIGANCE Preschool Screen, the Effectiveness of Early Detection and formal screening instruments. Davis Observation Checklist for Interventions Screening and surveillance studies Texas, the Denver Articulation The review for the USPSTF identified had to be conducted or results had to Screening Exam, DENVER II (formerly 1 poor-quality randomized controlled be interpretable in primary care the Denver Developmental Screening trial of screening for language delays settings. In contrast, treatment Test), a standard developmental in children ages 18 and 24 months studies were not limited by study screen administered by nurses, Early that followed outcomes at ages 3 and setting, which included speech and fi Screening Pro les, the Fluharty 8 years.21 This cluster-randomized language clinics, schools, and/or Preschool Speech and Language trial and follow-up study was home settings. Screening Test, the Northwestern conducted in 9419 children at 55 The current review differed Syntax Screening Test, the Screening child health centers in 6 geographic somewhat from the previous review Kit of Language Development, the regions of The Netherlands. Outcomes in that it focused on screening tools Sentence Repetition Screening Test, included the percentage of children that can be administered within the the Structured Screening Test who attended a special school, usual length of a primary care visit (formerly known as the Hackney percentage who repeated a class (#10 minutes) or those that require Early Language Screening Test), and because of language problems, and ’ .10 minutes and are administered Rigby s trial speech screening test. percentage who scored low on outside of a primary care setting, if Test performance characteristics standardized language tests. The the results can be readily interpreted varied widely. Parent-administered authors concluded that screening by a primary care clinician. The screening tools generally performed toddlers for language delay reduces current review also focused on better than other tools. Among requirements for special education studies in patients without known parent-administered tools, sensitivity and leads to improved language causes of speech and language delay was generally higher for the CDI, the performance at age 8 years. However, (because these are the patients most Infant-Toddler Checklist, and the LDS. the study was rated as poor quality,

PEDIATRICS Volume 136, number 2, August 2015 5 and therefore not included in the primary care settings for speech and USPSTF clarified that this USPSTF’s deliberation, because of language delays and disorders, such recommendation applies only to several limitations, including the as labeling or anxiety. The USPSTF asymptomatic children whose following: suboptimal rates of identified 2 studies (1 fair-quality and parents or clinicians do not have screening and low retention of trial 1 good-quality) on the potential specific concerns about their speech, subjects, reliance on indirect harms of treatment that reported language, hearing, or development. measures of speech and language inconsistent findings.9 The treatment The USPSTF also emphasized that this outcomes in school-aged children group of 1 study reported reduced recommendation applies only to (instead of individualized testing), parental , whereas another screening in primary care settings, lack of blinding to screening or study reported no effect on child and it noted the distinction between treatment status by teachers and well-being or attention level. screening in primary care settings parents who assessed outcomes, and Treatment harms were generally not and diagnostic testing, which may lack of adjustment for other potential measured or reported; the 2 included occur in other settings. The USPSTF reasons for placement in special studies reported few data on a limited also noted that this recommendation education. number of outcomes. does not evaluate screening for The USPSTF identified 13 fair- or autism spectrum disorder, which the Estimate of Magnitude of Net Benefit good-quality studies on the potential Task Force will address in a separate benefits of treatment interventions The USPSTF found inadequate recommendation statement. The for children diagnosed with specific evidence on the accuracy of screening USPSTF also called for research on speech and language delays and or surveillance for speech and socioeconomic and other factors disorders that reported inconsistent language delay and disorders in associated with risks, assessment, findings on speech and language primary care settings. The USPSTF and management of speech and outcomes.9 The majority of the trials found inadequate evidence on the language delay and disorders in reported improvements in speech potential benefits of screening in children. and language measures. However, the primary care settings and treatment applicability of this evidence to on speech, language, or other UPDATE OF PREVIOUS USPSTF routine screening in a primary care outcomes. The USPSTF found RECOMMENDATION adequate evidence that treatment is setting is limited, because many of the This recommendation replaces the associated with improvements in studies were conducted in very high 2006 USPSTF recommendation on some speech and language measures, risk populations (ie, high-prevalence screening for speech and language but inadequate evidence on its populations). In addition, these delay in preschool-aged children. The effectiveness in screen-detected studies did not report treatment current recommendation is consistent children. The USPSTF found effectiveness in children whose with the previous recommendation, inadequate evidence on the speech and language delay had which concluded that the evidence on association between treatment and actually been detected by screening; the routine use of brief, formal outcomes other than speech and instead, the delays had often been screening instruments in primary fi language. The USPSTF found identi ed as a result of parent or care settings to detect speech and inadequate evidence on the potential teacher concerns. A majority of the language delay in children aged harms of screening in primary care intervention studies were conducted 5 years or younger is insufficient. outside of the United States, which settings and treatment of speech and could also limit the applicability of language delay and disorders. findings. Therefore, the USPSTF concludes that RECOMMENDATIONS OF OTHERS the evidence is insufficient and that The USPSTF identified 4 fair- or good- The American Academy of the balance of benefits and harms of 22 quality studies that reported Pediatrics recommends that screening in primary care settings for inconsistent findings on other developmental surveillance be speech and language delays and outcomes, including socialization, incorporated at every well-child disorders in young children cannot be reading comprehension, parental preventive care visit for children from determined. stress, and child well-being or birth through age 3 years. It also attention level. recommends that any concerns raised Response to Public Comment during surveillance should be A draft version of this promptly addressed with Potential Harms of Screening and recommendation statement was standardized developmental Interventions posted on the USPSTF Web site from screening tests. In addition, it The USPSTF identified no studies on November 18 to December 15, 2014. recommends that screening tests the potential harms of screening in In response to public comment, the should be administered regularly at

6 SIU well-child visits at the ages of 9, 18, standardized tools for developmental ABBREVIATIONS and 24 or 30 months. screening in early childhood: 2002-2009. ASQ: Ages and Stages Pediatrics. 2011;128(1):14–19 Questionnaire MEMBERS OF THE USPSTF 9. Berkman ND, Wallace IF, Watson L, CDI: MacArthur-Bates et al. Screening for Speech and Members of the USPSTF at the time Communicative Development Language Delay and Disorders in this recommendation was finalized* Inventory Children Age 5 Years or Younger: are as follows: Albert L. Siu, MD, IDEA: Individuals With Disabilities A Systematic Review for the U.S. MSPH, Chair (Mount Sinai School of Education Act Preventive Services Task Force. Medicine, New York, and James J. LDS: Language Development Evidence Synthesis No. 120. Rockville, Peters Veterans Affairs Medical Survey MD: Agency for Healthcare Research and Quality; 2015. AHRQ Publication Center, Bronx, NY); Kirsten Bibbins- USPSTF: US Preventive Services 13-05197-EF-1 Domingo, PhD, MD, MAS, Co-Vice Task Force Chair (University of California, San 10. US Department of Education. Building Francisco, San Francisco, CA); David the legacy: IDEA 2004. Washington, DC: US Grossman, MD, MPH, Co-Vice Chair REFERENCES Department of Education; 2014. Available (Group Health, Seattle, WA); Linda at: http://idea.ed.gov/. Accessed October 1. Ellis EM, Thal DJ. Early language delay Ciofu Baumann, PhD, RN, APRN 29, 2014 and risk for language impairment. (University of Wisconsin, Madison, Perspect Lang Learn Educ. 2008;15(3): 11. American Speech-Language-Hearing WI); Karina W. Davidson, PhD, MASc 93–100 Association. Speech-Language Pathology (Columbia University, New York, NY); Medical Review Guidelines. Rockville, MD: 2. 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PEDIATRICS Volume 136, number 2, August 2015 7 18. Snowling MJ, Bishop DV, Stothard SE, 20. Cohen NJ, Menna R, Vallance DD, Barwick development at age 8. Pediatrics. 2007; Chipchase B, Kaplan C. Psychosocial MA, Im N, Horodezky NB. Language, social 120(6):1317–1325 outcomes at 15 years of children with cognitive processing, and behavioral 22. Council on Children With Disabilities; a preschool history of speech-language characteristics of psychiatrically Section on Developmental Behavioral impairment. J Child Psychol Psychiatry. disturbed children with previously Pediatrics; Bright Futures Steering – fi 2006;47(8):759 765 identi ed and unsuspected language Committee; Medical Home Initiatives for 19. Law J, Rush R, Schoon I, Parsons S. impairments. J Child Psychol Psychiatry. Children With Special Needs Project – Modeling developmental language 1998;39(6):853 864 Advisory Committee. Identifying infants difficulties from school entry into 21. van Agt HM, van der Stege HA, de Ridder- and young children with developmental adulthood: literacy, mental health, Sluiter H, Verhoeven LT, de Koning HJ. A disorders in the medical home: an and employment outcomes. cluster-randomized trial of screening for algorithm for developmental J Speech Lang Hear Res. 2009;52(6): language delay in toddlers: effects on surveillance and screening. Pediatrics. 1401–1416 school performance and language 2006;118(1):405–420

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