Evidence Synthesis Number 120 Screening for Speech and Language Delay and Disorders in Children Age 5 Years or Younger: A Systematic Evidence Review for the U.S. Preventive Services Task Force Prepared for: Agency for Healthcare Research and Quality U.S. Department of Health and Human Services 540 Gaither Road Rockville, MD 20850 www.ahrq.gov Contract No. HHSA-290-2012-0001-5I, Task Order No. 2 Prepared by: RTI International–University of North Carolina Evidence-based Practice Center Research Triangle Park, NC Investigators: Nancy D. Berkman, PhD Ina Wallace, PhD Linda Watson, EdD Tamera Coyne-Beasley, MD, MPH Katie Cullen, BA Charles Wood, MD Kathleen N. Lohr, PhD AHRQ Publication No. 13-05197-EF-1 November 2014 DRAFT—DO NOT CITE OR DISTRIBUTE This report is based on research conducted by the RTI International–University of North Carolina Evidence-based Practice Center (EPC) under contract to the Agency for Healthcare Research and Quality (AHRQ), Rockville, MD (Contract No. HHSA-290-2012-0001-5I, TO2). The findings and conclusions in this document are those of the authors, who are responsible for its contents, and do not necessarily represent the views of AHRQ. Therefore, no statement in this report should be construed as an official position of AHRQ or of the U.S. Department of Health and Human Services. The information in this report is intended to help health care decisionmakers—patients and clinicians, health system leaders, and policymakers, among others—make well-informed decisions and thereby improve the quality of health care services. This report is not intended to be a substitute for the application of clinical judgment. Anyone who makes decisions concerning the provision of clinical care should consider this report in the same way as any medical reference and in conjunction with all other pertinent information (i.e., in the context of available resources and circumstances presented by individual patients). Persons using assistive technology may not be able to fully access information in this report. For assistance, contact http://www.uspreventiveservicestaskforce.org/Page/Name/contact-us. None of the investigators report any affiliations or financial involvement that conflicts with the material presented in this report. Acknowledgments The authors acknowledge the following individuals for their contributions to this project: Karen Lee, MD, MPH, AHRQ Medical Officer; current and former members of the U.S. Preventive Services Task Force who contributed to topic deliberations; Evelyn Whitlock, MD, MPH, Kaiser Permanente Research Affiliates EPC Director; Tracy Beil, MS, Kaiser Permanente Research Affiliates EPC; and the following RTI–UNC EPC staff: Carol Woodell, BSPH, Project Manager, Meera Viswanathan, PhD, EPC Director, Lynn Whitener, DrPH, MSLS, librarian, Manny Coker- Schwimmer, MPH, research assistant, Laura Small, BA, editor, and Loraine Monroe and Judith Cannada, publication specialists. Screening for Speech and Language Delay ii RTI–UNC EPC DRAFT—DO NOT CITE OR DISTRIBUTE Structured Abstract Purpose: To evaluate the evidence on screening and treating children for speech and language delay or disorders for the U.S. Preventive Services Task Force (USPSTF). Data Sources: PubMed/MEDLINE, the Cochrane Library, PsychInfo, ClinicalTrials.gov, HSRProj, the World Health Organization International Clinical Trials Registry Platform, and reference lists of published literature (through July 2014). Study Selection: Two investigators independently selected studies reporting on benefits and harms of screening; accuracy of screening tools compared with diagnostic evaluations; and benefits or harms of treatment of speech and language delay or disorders compared with placebo, watchful waiting, or waitlist interventions. To provide context for evaluating our Key Questions, we also included studies describing screening instruments and risk factors for speech and language delay or disorder. Data Extraction: One reviewer extracted data and a second checked accuracy. Two independent reviewers assigned quality ratings using predefined criteria. Data Synthesis: No included studies examined the impact of screening on speech and language or other functional outcomes. We included 23 studies evaluating the accuracy of speech and language screening in primary care settings to identify children for diagnostic evaluations and interventions. Among instruments in 13 studies in which parents rated their children’s skills, sensitivity ranged between 50 and 94 percent, and specificity ranged between 45 and 96 percent. Of 3 instruments widely used in the United States, the MacArthur Communication Development Inventory (CDI) and the Language Development Survey (LDS) outperformed the Ages and Stages Questionnaire (ASQ) Communication domain, especially in terms of their specificity, correctly identifying on average 82 percent (CDI) and 91 percent (LDS), compared with 58 percent (ASQ). The ASQ and CDI have versions for infants, toddlers, and preschool-age children, with the CDI being more robust across age groups. The accuracy of professionally or paraprofessionally administered instruments was more variable across studies and many did not perform as well as parent-rated instruments. Because few studies examined the same instrument with different populations or with different ages, it is unclear how multiage professionally or paraprofessionally administered instruments fare more broadly or whether there is an optimal age for screening. We found no studies addressing adverse effects of screening, such as deleterious consequences of false conclusions from screening. We also found no studies concerning the role of enhanced surveillance by a primary care provider. We included 13 studies examining treatment for speech and language delay or disorders. Although the treatment approaches sometimes may overlap, we organized our findings by outcomes: language (including expressive and receptive language, and more specific aspects of language such as vocabulary, syntax/morphology, and narratives), speech sounds (including articulation, phonology, and speech intelligibility), and fluency (stuttering). Although results were mixed, the majority of studies found treatment to be effective. Characteristics of effective studies include higher intensity, treating children with more severe delays, and individualizing Screening for Speech and Language Delay iii RTI–UNC EPC DRAFT—DO NOT CITE OR DISTRIBUTE treatment to the child. We found little evidence concerning other functional outcomes or adverse effects of treatment. Risk factors that were generally associated with speech and language delay or disorders in multivariate analyses of cohort populations included being male, a family history of speech and language concerns, and lower levels of parental educational achievement. Limitations: As in the earlier review, we did not find any well-conducted trials that could address our overarching question of whether screening leads to improved outcomes. Many screening studies do not include unselected samples from the population but rather participants with and without language delays. Intervention studies did not consistently control for additional community services that children may have been receiving and varied greatly in treatment approach and outcome measurement. Also, because young children with disabilities are entitled to treatment, it may not be possible for future studies in the United States to examine treatment versus no treatment. Conclusion: This synthesis yields evidence that two parent-rated screeners, the CDI and LDS, can accurately identify children for diagnostic evaluations and interventions and likely can be interpreted with little difficulty in the primary care setting. Some treatments for young children identified with speech and language delays and disorders may be effective. Screening for Speech and Language Delay iv RTI–UNC EPC DRAFT—DO NOT CITE OR DISTRIBUTE Table of Contents Chapter 1. Introduction ............................................................................................................... 1 Overview and Objective ............................................................................................................. 1 Previous USPSTF Recommendation .......................................................................................... 1 Previous USPSTF Conclusions ............................................................................................ 1 Condition Definition ................................................................................................................... 2 Prevalence ............................................................................................................................ 4 Burden .................................................................................................................................. 5 Course, Comorbidity, and Sequelae ........................................................................................... 5 Etiology and Natural History ............................................................................................... 5 Sequelae ................................................................................................................................ 5 Current Clinical Practice in the United States ............................................................................ 6 Identification of Speech and Language Delays and Disorders in Primary Care Settings .......... 6 Interventions and Treatment ......................................................................................................