• U.S. Preventive Services Task Force (USPSTF). Screening for speech and language delay in preschool children: recommendation statement. Rockville (MD): Agency for Healthcare Research and Quality (AHRQ); 2006. 10 p. [29 references]

This is the current release of the guideline.

Speech and language delay

Prevention
Screening

Family Practice
Pediatrics
Preventive Medicine
Speech-Language Pathology

Advanced Practice Nurses
Allied Health Personnel
Nurses
Physician Assistants
Physicians
Speech-Language Pathologists

To summarize the U.S. Preventive Services Task Force recommendations on screening for speech and language delay in preschool children and the supporting evidence

Children up to 5 years old without previously known conditions associated with speech and language delay, such as hearing and neurologic impairments

Considered but not specifically recommended

Screening for speech and language delay using brief, formal screening instruments

• Key Question 1: Does screening for speech and language delay result in improved speech and language as well as improved other non-speech and language outcomes?
• Key Question 2: Do screening evaluations in the primary care setting accurately identify children for diagnostic evaluation and interventions?
• Key Question 2a: Does identification of risk factors improve screening?
• Key Question 2b & 2c: What are screening techniques and how do they differ by age? What is the accuracy of screening techniques and how does it vary by age?
• Key Question 2d: What are the optimal ages and frequency for screening?
• Key Question 3: What are the adverse effects of screening?
• Key Question 4: What is the role of enhanced surveillance by primary care clinicians?
• Key Question 5: Do interventions for speech and language delay improve speech and language outcomes?
• Key Question 6: Do interventions for speech and language delay improve other non-speech and language outcomes?
• Key Question 7: Does improvement in speech and language outcomes lead to improved additional outcomes?
• Key Question 8: What are the adverse effects of interventions?

Hand-searches of Published Literature (Primary Sources)
Hand-searches of Published Literature (Secondary Sources)
Searches of Electronic Databases

Note from the National Guideline Clearinghouse (NGC): A systematic review of the literature was prepared by the Oregon Evidence-based Practice Center (EPC) and Oregon Health & Science University for the Agency for Healthcare Research and Quality (AHRQ) for use by the U.S. Preventive Services Task Force (USPSTF) (see the "Companion Documents" field).

Literature Search and Selection

Relevant studies were identified from multiple searches of MEDLINE, PsycINFO, and CINAHL databases (1966 to November 19, 2004). Search terms were determined by investigators and a research librarian and are described elsewhere. Articles were also obtained from recent systematic reviews, reference lists of pertinent studies, reviews, editorials, and websites, and by consulting experts. In addition, investigators attempted to collect instruments and accompanying manuals; however, these materials are not generally available and must be purchased, which limited the evidence review to published articles.

Investigators reviewed all abstracts identified by the searches and determined eligibility of full-text articles based on several criteria. Eligible articles had English-language abstracts, were applicable to U.S. clinical practice, and provided primary data relevant to key questions. Studies of children with previously diagnosed conditions known to cause speech and language delay (e.g., autism, mental retardation, Fragile X, hearing loss, degenerative and other neurological disorders) were not included because the scope of this review is screening children without known diagnoses.

Studies of risk factors were included if they focused on children age 5 years or younger, reported associations between predictor variables and speech and language outcomes, and were relevant to selecting candidates for screening. Otitis media as a risk factor for speech and language delay is a complex and controversial area and was not included in this review.

Studies of techniques to assess speech and language were included if they focused on children aged 5 years and younger, could be applied to a primary care setting, used clearly defined measures, compared the screening technique to an acceptable reference standard, and reported data allowing calculation of sensitivity and specificity. Techniques that take 10 minutes or less to complete that could be administered in a primary care setting by nonspecialists are most relevant to screening and are described in this report. Instruments taking more than 10 minutes and up to 30 minutes or for which administration time was not reported are described elsewhere. In general, if the instrument was administered by primary care physicians, nurses, research associates, or other nonspecialists for the study, it was assumed that it could be administered by nonspecialists in a clinic. For questionable cases, experts in the field were consulted to help determine appropriateness for primary care. Studies of broader developmental screening instruments, such as the Ages and Stages Questionnaire and Denver Developmental Screening Test, were included if they provided outcomes related to speech and language delay specifically.

Only randomized controlled trials (RCTs) were considered for examining the effectiveness of interventions. Outcome measures were considered if they were obtained at any time or age after screening and/or intervention as long as the initial assessment occurred while the child was aged 5 years or younger. Outcomes included speech and language measures as well as other functional and health outcomes as previously described.

Investigators reviewed 5,377 abstracts identified by the searches. A total of 690 full-text articles from searches and an additional 55 non-duplicate articles from reference lists and experts met eligibility criteria and were reviewed.

Weighting According to a Rating Scheme (Scheme Given)

The U.S. Preventive Services Task Force grades the quality of the overall evidence for a service on a 3-point scale (good, fair, poor):

Good

Evidence includes consistent results from well-designed, well-conducted studies in representative populations that directly assess effects on health outcomes.

Fair

Evidence is sufficient to determine effects on health outcomes, but the strength of the evidence is limited by the number, quality, or consistency of the individual studies, generalizability to routine practice, or indirect nature of the evidence on health outcomes.

Poor

Evidence is insufficient to assess the effects on health outcomes because of limited number or power of studies, important flaws in their design or conduct, gaps in the chain of evidence, or lack of information on important health outcomes.

Systematic Review with Evidence Tables

Note from the National Guideline Clearinghouse (NGC): A systematic review of the literature was prepared by the Oregon Evidence-based Practice Center (EPC) and Oregon Health & Science University for the Agency for Healthcare Research and Quality (AHRQ) for use by the U.S. Preventive Services Task Force (USPSTF) (see the "Companion Documents" field).

Data were extracted from each study, entered into evidence tables, and summarized by descriptive methods. For some studies of screening instruments, sensitivity and specificity were calculated by the investigators if adequate data were presented in the paper. No statistical analyses were performed because of heterogeneity of studies.

Investigators independently rated the quality of studies using criteria specific to different study designs developed by the USPSTF (see Appendix in the evidence review document). The quality of the study does not necessarily indicate the quality of an instrument or intervention but may influence interpretation of the results of the study.

Balance Sheets
Expert Consensus

When the overall quality of the evidence is judged to be good or fair, the U.S. Preventive Services Task Force (USPSTF) proceeds to consider the magnitude of net benefit to be expected from implementation of the preventive service. Determining net benefit requires assessing both the magnitude of benefits and the magnitude of harms and weighing the two.

The USPSTF classifies benefits, harms, and net benefits on a 4-point scale: "substantial," "moderate," "small," and "zero/negative."

"Outcomes tables" (similar to "balance sheets") are the USPSTF's standard resource for estimating the magnitude of benefit. These tables, prepared by the topic teams for use at USPSTF meetings, compare the condition specific outcomes expected for a hypothetical primary care population with and without use of the preventive service. These comparisons may be extended to consider only people of specified age or risk groups or other aspects of implementation. Thus, outcomes tables allow the USPSTF to examine directly how the preventive service affects benefits for various groups.

When evidence on harms is available, the topic teams assess its quality in a manner like that for benefits and include adverse events in the outcomes tables. When few harms data are available, the USPSTF does not assume that harms are small or nonexistent. It recognizes a responsibility to consider which harms are likely and judge their potential frequency and the severity that might ensue from implementing the service. It uses whatever evidence exists to construct a general confidence interval on the 4-point scale (e.g., substantial, moderate, small, and zero/negative).

Value judgments are involved in using the information in an outcomes table to rate either benefits or harms on the USPSTF's 4-point scale. Value judgments are also needed to weigh benefits against harms to arrive at a rating of net benefit.

In making its determinations of net benefit, the USPSTF strives to consider what it believes are the general values of most people. It does this with greater confidence for certain outcomes (e.g., death) about which there is little disagreement about undesirability, but it recognizes that the degree of risk people are willing to accept to avert other outcomes (e.g., cataracts) can vary considerably. When the USPSTF perceives that preferences among individuals vary greatly, and that these variations are sufficient to make the trade-off of benefits and harms a "close-call," then it will often assign a C recommendation (see the "Recommendation Rating Scheme" field). This recommendation indicates the decision is likely to be sensitive to individual patient preferences.

The USPSTF uses its assessment of the evidence and magnitude of net benefit to make recommendations. The general principles the USPSTF follows in making recommendations are outlined in Table 5 of the companion document cited below. The USPSTF liaisons on the topic team compose the first drafts of the recommendations and rationale statements, which the full panel then reviews and edits. Recommendations are based on formal voting procedures that include explicit rules for determining the views of the majority.

From: Harris RP, Helfand M, Woolf SH, Lohr KN, Mulrow, CD, Teutsch SM, Atkins D. Current methods of the U.S. Preventive Services Task Force: a review of the process. Methods Work Group, Third U.S. Preventive Services Task Force. Am J Prev Med 2001 Apr;20(3S):21-35.

The U.S. Preventive Services Task Force (USPSTF) grades its recommendations according to one of five classifications (A, B, C, D, I) reflecting the strength of evidence and magnitude of net benefit (benefits minus harms):

A

The USPSTF strongly recommends that clinicians provide [the service] to eligible patients. The USPSTF found good evidence that [the service] improves important health outcomes and concludes that benefits substantially outweigh harms.

B

The USPSTF recommends that clinicians provide [this service] to eligible patients. The USPSTF found at least fair evidence that [the service] improves important health outcomes and concludes that benefits outweigh harms.

C

The USPSTF makes no recommendation for or against routine provision of [the service]. The USPSTF found at least fair evidence that [the service] can improve health outcomes but concludes that the balance of benefits and harms is too close to justify a general recommendation.

D

The USPSTF recommends against routinely providing [the service] to asymptomatic patients. The USPSTF found at least fair evidence that [the service] is ineffective or that harms outweigh benefits.

I

The USPSTF concludes that the evidence is insufficient to recommend for or against routinely providing [the service]. Evidence that the [service] is effective is lacking, of poor quality, or conflicting and the balance of benefits and harms cannot be determined.

A formal cost analysis was not performed and published cost analyses were not reviewed.

Comparison with Guidelines from Other Groups
External Peer Review
Internal Peer Review

Peer Review. Before the U.S. Preventive Services Task Force makes its final determinations about recommendations on a given preventive service, the Evidence-based Practice Center and the Agency for Healthcare Research and Quality send a draft systematic evidence review to 4 to 6 external experts and to federal agencies and professional and disease-based health organizations with interests in the topic. They ask the experts to examine the review critically for accuracy and completeness and to respond to a series of specific questions about the document. After assembling these external review comments and documenting the proposed response to key comments, the topic team presents this information to the Task Force in memo form. In this way, the Task Force can consider these external comments and a final version of the systematic review before it votes on its recommendations about the service. Draft recommendations are then circulated for comment from reviewers representing professional societies, voluntary organizations, and Federal agencies. These comments are discussed before the whole U.S. Preventive Services Task Force before final recommendations are confirmed.

Recommendations of Others. Recommendations regarding screening for speech and language delay in preschool children from the following groups were discussed: The American Academy of Pediatrics (AAP); The Centers for Disease Control and Prevention (CDC); The American Speech-Language-Hearing Association (ASHA).

The U.S. Preventive Services Task Force (USPSTF) grades its recommendations (A, B, C, D, or I) and the quality of the overall evidence for a service (good, fair, poor). The definitions of these grades can be found at the end of the "Major Recommendations" field.

The USPSTF concludes that the evidence is insufficient to recommend for or against routine use of brief, formal screening instruments in primary care to detect speech and language delay in children up to 5 years of age. I recommendation.

Speech and language delay affects 5% to 8% of preschool children, often persists into the school years, and may be associated with lowered school performance and psychosocial problems. The USPSTF found insufficient evidence that brief, formal screening instruments that are suitable for use in primary care for assessing speech and language development can accurately identify children who would benefit from further evaluation and intervention. Fair evidence suggests that interventions can improve the results of short-term assessments of speech and language skills; however, no studies have assessed long-term outcomes. Furthermore, no studies have assessed any additional benefits that may be gained by treating children identified through brief, formal screening who would not be identified by addressing clinical or parental concerns. No studies have addressed the potential harms of screening or interventions for speech and language delays, such as labeling, parental anxiety, or unnecessary evaluation and intervention. Thus, the USPSTF could not determine the balance of benefits and harms of using brief, formal screening instruments to screen for speech and language delay in the primary care setting.

Clinical Considerations

• It is the responsibility of primary care clinicians to seek and address parents' concerns and children's obvious speech and language delays despite the lack of evidence to support screening with brief formal instruments. Speech and language development is considered a useful early indicator of a child's overall development and cognitive ability, and clinical and parental concerns are important modes of identifying children with speech and language delay. Early identification of children with developmental delay (lateness in achieving milestones) or developmental disabilities (chronic conditions that result from mental or physical impairments), such as marked hearing deficits, may lead to intervention and family assistance at a young age when chances for improvement may be best.
• Specific groups of children who already have been identified as at higher than average risk for speech and language delay, including children with other medical problems such as hearing deficits or cranio-facial abnormalities, are not considered in this recommendation. The results of studies of other risk factors are inconsistent, so the USPSTF was unable to develop a list of specific risk factors to guide primary care providers in selective screening. The most consistently reported risk factors, however, include a family history of speech and language delay, male gender, and perinatal factors, such as prematurity and low birthweight. Other risk factors reported less consistently include levels of parental education, specific childhood illnesses, birth order, and larger family size.

Definitions:

USPSTF Recommendations and Ratings

The USPSTF grades its recommendations according to one of five classifications (A, B, C, D, I) reflecting the strength of evidence and magnitude of net benefit (benefits minus harms):

A

The USPSTF strongly recommends that clinicians provide [the service] to eligible patients. The USPSTF found good evidence that [the service] improves important health outcomes and concludes that benefits substantially outweigh harms.

B

The USPSTF recommends that clinicians provide [the service] to eligible patients. The USPSTF found at least fair evidence that [the service] improves important health outcomes and concludes that benefits outweigh harms.

C

The USPSTF makes no recommendation for or against routine provision of [the service]. The USPSTF found at least fair evidence that [the service] can improve health outcomes but concludes that the balance of benefits and harms is too close to justify a general recommendation.

D

The USPSTF recommends against routinely providing [the service] to asymptomatic patients. The USPSTF found at least fair evidence that [the service] is ineffective or that harms outweigh benefits.

I

The USPSTF concludes that the evidence is insufficient to recommend for or against routinely providing [the service]. Evidence that the [service] is effective is lacking, of poor quality, or conflicting and the balance of benefits and harms cannot be determined.

USPSTF Strength of Overall Evidence

The USPSTF grades the quality of the overall evidence for a service on a 3-point scale (good, fair, poor):

Good

Evidence includes consistent results from well-designed, well-conducted studies in representative populations that directly assess effects on health outcomes.

Fair

Evidence is sufficient to determine effects on health outcomes, but the strength of the evidence is limited by the number, quality, or consistency of the individual studies, generalizability to routine practice, or indirect nature of the evidence on health outcomes.

Poor

Evidence is insufficient to assess the effects on health outcomes because of limited number or power of studies, important flaws in the design or conduct, gaps in the chain of evidence, or lack of information on important health outcomes.

None provided

The type of evidence supporting the recommendations is identified in the "Major Recommendations" field.

Appropriate use of screening instruments in primary care to detect speech and language delay in preschool children

No studies have addressed the harms of screening and interventions for speech and language delay in children <5 years of age. A potential harm of screening includes receiving either false-positive or false-negative results. False-positive results can erroneously label children with normal speech and language as impaired, potentially leading to anxiety for children and families and the need for further testing and interventions. False-negative results would miss identifying children with impairment, potentially leading to progressive speech and language delay and other long-term effects including communication, social, and academic problems. Potential harms of interventions include time and cost of interventions for clinicians, parents, children, and siblings, as well as stigmatization, labeling, and loss of time for play and family activities.

Recommendations made by the U.S. Preventive Services Task Force (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 (AHRQ) or the U.S. Department of Health and Human Services.

Staying Healthy

Effectiveness
Patient-centeredness

• U.S. Preventive Services Task Force (USPSTF). Screening for speech and language delay in preschool children: recommendation statement. Rockville (MD): Agency for Healthcare Research and Quality (AHRQ); 2006. 10 p. [29 references]

Not applicable: The guideline was not adapted from another source.

2006

United States Preventive Services Task Force - Independent Expert Panel

The U.S. Preventive Services Task Force (USPSTF) is a federally-appointed panel of independent experts. Conclusions of the U.S. Preventive Services Task Force do not necessarily reflect policy of the U.S. Department of Health and Human Services (DHHS) or its agencies.

United States Government

U.S. Preventive Services Task Force (USPSTF)

The U.S. Preventive Services Task Force has an explicit policy concerning conflict of interest. All members and evidence-based practice center (EPC) staff disclose at each meeting if they have an important financial conflict for each topic being discussed. Task Force members and EPC staff with conflicts can participate in discussions about evidence, but members abstain from voting on recommendations about the topic in question.

From: Harris RP, Helfand M, Woolf SH, Lohr KN, Mulrow, CD, Teutsch SM, Atkins D. Current methods of the U.S. Preventive Services Task Force: a review of the process. Methods Work Group, Third U.S. Preventive Services Task Force. Am J Prev Med 2001 Apr;20(3S):21-35.

This is the current release of the guideline.

None available

This NGC summary was completed by ECRI on January 24, 2006. The information was verified by the guideline developer on February 1, 2006.