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DOI: 10.1542/peds.2005-14672006;117;e298-e319Pediatrics

Heidi D. Nelson, Peggy Nygren, Miranda Walker and Rita PanoschaEvidence Review for the US Preventive Services Task Force

Screening for Speech and Language Delay in Preschool Children: Systematic

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REVIEW ARTICLE

Screening for Speech and Language Delay inPreschool Children: Systematic Evidence Review forthe US Preventive Services Task ForceHeidi D. Nelson, MD,MPH a,b,c , Peggy Nygren, MA a,c , Miranda Walker, BA a,c , Rita Panoscha,MD a,c,d

Departments of a Medical Informatics and Clinical Epidemiology, b Medicine, and d Pediatrics, and the c Oregon Evidence-based Practice Center, Oregon Health andScience University, Portland, Oregon

Financial Disclosure: Dr Panoscha has no direct personal nancial benet or conict of interest involving this research, but there may be a perceived conict. She is an ofcer of the Kennedy FellowsAssociation, which had sold and promoted the Clinical Adaptive Test/Clinical Linguistic Auditory Milestone Scale (CAT/CLAMS) test kit in the past. This test instrument is now published, produced, and sold bya private publishing company (Paul H. Brooks Publishing Co). Dr Panoscha excused herself for the portion of this evidence review that reviewed the abstracts and articles on the screening instruments.

ABSTRACT

BACKGROUND.Speech and language development is a useful indicator of a childsoverall development and cognitive ability and is related to school success. Identi-cation of children at risk for developmental delay or related problems may leadto intervention services and family assistance at a young age, when the chances forimprovement are best. However, optimal methods for screening for speech andlanguage delay have not been identied, and screening is practiced inconsistentlyin primary care.

PURPOSE.We sought to evaluate the strengths and limits of evidence about theeffectiveness of screening and interventions for speech and language delay inpreschool-aged children to determine the balance of benets and adverse effects ofroutine screening in primary care for the development of guidelines by the USPreventive Services Task Force. The target population includes all children up to 5years old without previously known conditions associated with speech and lan-guage delay, such as hearing and neurologic impairments.

METHODS.Studies were identied from Medline, PsycINFO, and CINAHL databases(1966 to November 19, 2004), systematic reviews, reference lists, and experts. Theevidence review included only English-language, published articles that are avail-able through libraries. Only randomized, controlled trials were considered forexamining the effectiveness of interventions. Outcome measures were consideredif they were obtained at any time or age after screening and/or intervention as longas the initial assessment occurred while the child was 5 years old. Outcomesincluded speech and language measures and other functional and health outcomessuch as social behavior. A total of 745 full-text articles met our eligibility criteriaand were reviewed. Data were extracted from each included study, summarizeddescriptively, and rated for quality by using criteria specic to different studydesigns developed by the US Preventive Services Task Force.

www.pediatrics.org/cgi/doi/10.1542/

peds.2005-1467doi:10.1542/peds.2005-1467

Key Wordsspeech and language delay and disorders,preschool children, screening,interventions

AbbreviationsUSPSTFUS Preventive Services TaskForceRCTrandomized controlled trialSESsocioeconomic statusSMDstandard mean differenceCIcondence interval

Accepted for publication Aug 12, 2005

Address correspondence to Heidi D. Nelson,MD, MPH, Oregon Health and ScienceUniversity, Mail Code BICC 504, 3181 SW S amJackson Park Rd, Portland, OR 97239. E-mail:[email protected]

PEDIATRICS (ISSN Numbers: Print, 0031-4005;Online, 1098-4275). Published in the publicdomain by the American Academy of Pediatrics.

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RESULTS.The use of risk factors for selective screening hasnot been evaluated, and a list of specic risk factors toguide primary care physicians has not been developed ortested. Sixteen studies about potential risk factors forspeech and language delay in children enrolled hetero-geneous populations, had dissimilar inclusion and exclu-sion criteria, and measured different risk factors and

outcomes. The most consistently reported risk factorsincluded a family history of speech and language delay,male gender, and perinatal factors. Other risk factorsreported less consistently included educational levels ofthe mother and father, childhood illnesses, birth order,and family size.

The performance characteristics of evaluation tech-niques that take 10 minutes to administer were de-scribed in 24 studies relevant to screening. Studies thatwere rated good to fair quality reported wide ranges ofsensitivity and specicity when compared with referencestandards (sensitivity: 17100%; specicity: 45100%).Most of the evaluations, however, were not designed forscreening purposes, the instruments measured differentdomains, and the study populations and settings wereoften outside of primary care. No gold standard has been developed and tested for screening, reference stan-dards varied across studies, few studies compared theperformance of 2 screening techniques in 1 popula-tion, and comparisons of a single screening techniqueacross different populations are lacking.

Fourteen good- and fair-quality randomized, controlledtrials of interventions reported signicantly improved

speech and language outcomes compared with controlgroups. Improvement was demonstrated in several do-mains including articulation, phonology, expressive lan-guage, receptive language, lexical acquisition, and syn-tax among children in all age groups studied and acrossmultiple therapeutic settings. Improvement in otherfunctional outcomes such as socialization skills, self-es-teem, and improved play themes were demonstrated insome, but not all, of the 4 studies that measured them. Ingeneral, studies of interventions were small and hetero-geneous, may be subject to plateau effects, and reportedshort-term outcomes based on various instruments and

measures. As a result, long-term outcomes are notknown, interventions could not be compared directly,and generalizability is questionable.

CONCLUSIONS.Use of risk factors to guide selective screeningis not supported by studies. Several aspects of screeninghave been inadequately studied to determine optimalmethods, including which instrument to use, the age atwhich to screen, and which interval is most useful. Trialsof interventions demonstrate improvement in some out-come measures, but conclusions and generalizability arelimited. Data are not available addressing other key is-sues including the effectiveness of screening in primary

care settings, role of enhanced surveillance by primarycare physicians before referral for diagnostic evaluation,nonspeech and language and long-term benets of in-terventions, and adverse effects of screening and inter-ventions.

SPEECH AND LANGUAGE development is considered byexperts to be a useful indicator of a childs overall

development and cognitive ability 1 and is related toschool success. 27 Identication of children at risk fordevelopmental delay or related problems may lead tointervention services and family assistance at a youngage when chances for improvement are best. 1 This ratio-nale supports preschool screening for speech and lan-guage delay, or primary language impairment/disorder,as a part of routine well-child care.

Several types of speech and language delay and dis-orders have been described, 8 although terminology var-ies (Table 1). Expressive language delay may exist with-

out receptive language delay, but often they occurtogether in children as a mixed expressive/receptive lan-guage delay. Some children also have disordered lan-guage. Language problems can involve difculty withgrammar (syntax), words or vocabulary (semantics),the rules and system for speech sound production (pho-nology), units of word meaning (morphology), and theuse of language particularly in social contexts (pragmat-ics). Speech problems may include stuttering or dysu-ency, articulation disorders, or unusual voice quality.Language and speech problems can exist together or bythemselves.

Prevalence rates for speech and language delay have been reported across wide ranges. A recent Cochrane

TABLE 1 Denitions of TermsTerm Denition

Articulation The production of speech soundsDysuency Interrupted ow of speech sounds, such as

stutteringExpressive language The use of language to share thoughts, protest, or

commentLanguage The conceptual processing of communication

which may be receptive and or expressiveMorphology The rules governing meanings of word unitsPhonology The se t of rules for sound productionPragmatics Adaptation of language to the social contextProsody Appropriate intonation, rate, rhythm, and

loudness of speech utterancesReceptive language Understanding of languageSemantics A set of words known to a person that are a part

of a specic language (vocabulary)Speech Verbal production of languageSyntax The way l inguistic elements are put together to

form phrases or clauses (grammar)Voice disorders Difculty with speech sound production, at the

level of the larynx, may be related to motor oranatomical issues (eg, hypernasal or hoarsespeech)

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review summarized prevalence data on speech delay,language delay, and combined delay in preschool- andschool-aged children. 9 For preschool-aged children, 2 to4.5 years old, studies that evaluated combined speechand language delay have reported prevalence rates rang-ing from 5% to 8%, 10,11 and studies of language delayhave reported prevalence rates ranging from 2.3% to

19%. 9,1215 Untreated speech and language delay in pre-school children has shown variable persistence rates(from 0% to 100%), with most studies reporting 40% to60%. 9 In 1 study, two thirds of preschool-aged childrenwho were referred for speech and language therapy andgiven no direct intervention proved eligible for therapy12 months later. 16

Preschool-aged children with speech and languagedelay may be at increased risk for learning disabilitiesonce they reach school age. 17 They may have difcultyreading in grade school, 2 exhibit poor reading skills atage 7 or 8, 35 and have difculty with written language, 6

in particular. This may lead to overall academic under-achievement 7 and, in some cases, lower IQ scores 13 thatmay persist into young adulthood. 18 As adults, childrenwith phonological difculties may hold lower-skilled jobs than their nonlanguage-impaired siblings. 19 In ad-dition to persistent speech- and language-related under-achievement (verbal, reading, spelling), language-de-layed children have also shown more behavior problemsand impaired psychosocial adjustment. 20,21

Assessing children for speech and language delay anddisorders can involve a number of approaches, althoughthere is no uniformly accepted screening technique for

use in the primary care setting. Milestones for speechand language development in young children are gen-erally acknowledged. 22 Concerns for delay arise if thereare no verbalizations by the age of 1, if speech is notclear, or if speech or language is different from that ofother children of the same age. Parent questionnaires andparent concern are often used to detect delay. 23 Most for-mal instruments were designed for diagnostic purposes andhave not been widely evaluated for screening. Instrumentsconstructed to assess multiple developmental components,such as the Ages and Stages Questionnaire, 24 Clinical Adap-tive Test/Clinical Linguistic and Auditory Milestone Scale, 25

and Denver Developmental Screening Test, 26 includespeech and language components. Instruments designedspecic for communication domains include the McArthurCommunicative Development Inventory, 27 Ward InfantLanguage Screening Test, Assessment, Acceleration, andRemediation (WILSTAAR), 28 Fluharty Preschool Speechand Language Screening Test, 29 Early Language Mile-stone Scale, 30 and several others.

A specic diagnosis is made most often by a speechand language specialist using a battery of instruments.Once a child has been diagnosed with a speech and/orlanguage delay, interventions may be prescribed. Ther-apy takes place in various settings including speech and

language specialty clinics, home, and schools or class-rooms. Direct therapy or group therapy provided by aclinician, caretaker, or teacher can be child-centeredand/or include peer and family components. The dura-tion of the intervention varies. Intervention strategiesfocus on 1 domains depending on individual needs,such as expressive language, receptive language, pho-

nology, syntax, and lexical acquisition. Therapies caninclude naming objects, modeling and prompting, indi-vidual or group play, discrimination tasks, reading, andconversation.

It is not clear how consistently clinicians screen forspeech and language delay in primary care practice. In 1study, 43% of parents reported that their young child(aged 1035 months) did not receive any type of devel-opmental assessment at their well-child visit, and 30%of parents reported that their childs physician had notdiscussed how the child communicates. 31 Potential bar-riers to screening include lack of time, no clear protocols,

and the competing demands of the primary care visit.This evidence review focuses on the strengths andlimits of evidence about the effectiveness of screeningand interventions for speech and language delay in pre-school-aged children. Its objective is to determine the balance of benets and adverse effects of routine screen-ing in primary care for the development of guidelines bythe US Preventive Services Task Force (USPSTF). Thetarget population includes all children up to 5 years oldwithout previously known conditions associated withspeech and language delay, such as hearing and neuro-logic impairments. The evidence synthesis emphasizesthe patients perspective in the choice of tests, interven-tions, outcome measures, and potential adverse effectsand focuses on those that are available and easily inter-preted in the context of primary care. It also considersthe generalizability of efcacy studies performed in con-trolled or academic settings and interprets the use of thetests and interventions in community-based populationsseeking primary health care.

METHODS

Analytic Framework and Key QuestionsEvidence reviews for the USPSTF follow a specic meth-odology 32 beginning with the development of an analyticframework and key questions in collaboration withmembers of the USPSTF. The analytic framework repre-sents an outline of the evidence review and includes thepatient population, interventions, outcomes, and ad-verse effects of the screening process (Fig 1). Corre-sponding key questions examine a chain of evidenceabout the effectiveness, accuracy, and feasibility ofscreening children aged 5 years and younger for speechand language delay in primary care settings (key ques-tions 1 and 2), adverse effects of screening (key question3), the role of enhanced surveillance in primary care


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(key question 4), effectiveness of interventions for chil-dren identied with delay (key questions 5, 6, and 7),and adverse effects of interventions (key question 8).

Studies addressing key question 1, corresponding tothe overarching arrow in Fig 1, would include all com-ponents in the continuum of the screening process, in-cluding the screening evaluation, diagnostic evaluationfor children identied with delay by the screening eval-uation, interventions for children diagnosed with delay,and outcome measures allowing determination of theeffectiveness of the overall screening process. Enhancedsurveillance in primary care relates to the practice ofclosely observing children who may have clinical con-cern for delay but not of the degree warranting a referral(watchful waiting). Outcome measures in this reviewinclude speech- and language-specic outcomes as wellas nonspeech and language health and functional out-comes such as social behavior, self-esteem, family func-tion, peer interaction, and school performance. Keyquestion 5 examines whether speech and language in-

terventions lead to improved speech and language out-comes. Key question 6 examines whether speech andlanguage interventions lead to improved nonspeechand language outcomes. Key question 7 evaluates thesubsequent effects of improved speech and language,such as improved school performance at a later age.

Literature Search and SelectionRelevant studies were identied from multiple searchesof Medline, PsycINFO, and CINAHL databases (1966 toNovember 19, 2004). Search terms were determined bythe investigators and a research librarian and are de-scribed elsewhere. 33 Articles were also obtained fromrecent systematic reviews, 34,35 reference lists of pertinentstudies, reviews, editorials, and Web sites and by con-sulting experts. In addition, the investigators attemptedto collect instruments and accompanying manuals; how-ever, these materials are not generally available andmust be purchased, which limited the evidence reviewto published articles.

FIGURE 1

Analytic framework and key questions. The analyticframeworkrepresents an outline of the evidence reviewand includes the patientpopulation, interventions, outcomes, and adverseeffects of the screening process. The key questions examine a chain of evidence about the effectiveness, accuracy, and feasibility of screening children aged 5 years and younger forspeechand language delay inprimary care settings (key questions 1 and2),adverse effectsofscreening(keyquestion3), theroleof enhanced surveillance inprimary care (key question4), effectiveness of interventions for children identied with delay (key questions 5, 6, and 7), and adverse effects of interventions (key question 8).


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The investigators reviewed all abstracts that wereidentied by the searches and determined eligibility offull-text articles based on several criteria. Eligible articleshad English-language abstracts, were applicable to USclinical practice, and provided primary data relevant tokey questions. Studies of children with previously diag-nosed conditions known to cause speech and language

delay (eg, autism, mental retardation, fragile X syn-drome, hearing loss, degenerative and other neurologicdisorders) were not included because the scope of thisreview is screening children without known diagnoses.

Studies of risk factors were included if they focusedon children aged 5 years or younger, reported associa-tions between predictor variables and speech and lan-guage outcomes, and were relevant to selecting candi-dates for screening. Otitis media as a risk factor forspeech and language delay is a complex and controver-sial 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 yearsand younger, could be applied to a primary care setting,used clearly dened measures, compared the screeningtechnique to an acceptable reference standard, and re-ported data that allowed calculation of sensitivity andspecicity. Techniques that take 10 minutes to com-plete and could be administered in a primary care setting by nonspecialists are most relevant to screening and aredescribed in this report. Instruments that take 10 min-utes and up to 30 minutes or for which administrationtime was not reported are described elsewhere. 33 In gen-eral, if the instrument was administered by primary care

physicians, nurses, research associates, or other nonspe-cialists for the study, it was assumed that it could beadministered by nonspecialists in a clinic. For question-able cases, experts in the eld were consulted to helpdetermine appropriateness for primary care. Studies of broader developmental screening instruments such asthe Ages and Stages Questionnaire and Denver Devel-opmental Screening Test were included if they providedoutcomes related to speech and language delay speci-cally.

Only randomized, controlled trials (RCTs) were con-sidered for examining the effectiveness of interventions.Outcome measures were considered if they were ob-tained at any time or age after screening and/or inter-vention as long as the initial assessment occurred whilethe child was 5 years old. Outcomes included speechand language measures as well as other functional andhealth outcomes as described previously.

Data Extraction and SynthesisInvestigators reviewed 5377 abstracts that were identi-ed by the searches. A total of 690 full-text articles fromsearches and an additional 55 nonduplicate articles fromreference lists and experts met eligibility criteria andwere reviewed. Data were extracted from each study,

entered into evidence tables, and summarized by de-scriptive methods. For some studies of screening instru-ments, sensitivity and specicity were calculated by theinvestigators if adequate data were presented in thearticle. No statistical analyses were performed because ofthe heterogeneity of studies. The investigators indepen-dently rated the quality of studies by using criteria spe-

cic to different study designs developed by the USPSTF(Appendix). 32 The quality of the study does not neces-sarily indicate the quality of an instrument or interven-tion but may inuence interpretation of the results ofthe study.

RESULTS

Key Question 1: Does Screening for Speech and LanguageDelay Result in Improved Speech and Language as well asImproved Other NonSpeech and Language Outcomes?No studies directly addressed this question.

Key Question 2: Do Screening Evaluations in the Primary CareSetting Accurately Identify Children for Diagnostic Evaluationand Interventions?

Key Question 2a: Does Identication of Risk Factors Improve Screening?Nine studies conducted in English-speaking popula-tions 3644 and 7 studies from nonEnglish-speaking pop-ulations 4551 met inclusion criteria (Table 2). The mostconsistently reported risk factors include a family historyof speech and language delay, male gender, and perina-tal risk factors; however, their role in screening is un-

clear. A list of specic risk factors to guide primary carephysicians in selective screening has not been developedor tested.

English-language studies include case-control, 37,3941,43

cross-sectional, 36,38,42 and prospective-cohort 44 designs.Most studies evaluated risk for language delay with orwithout speech delay, and 1 restricted the evaluation toexpressive language only. 44 Family history was the mostconsistent signicantly associated risk factor in 5 of 7studies that examined it. 37,39,4143 Family history was de-ned as family members who were late to talk or hadlanguage disorders, speech problems, or learning prob-lems. Male gender was a signicant factor in all 3 of thestudies that examined it. 37,39,42 Three 37,41,43 of 5 studiesreported an association between lower maternal educa-tion level and language delay, and 3 studies 4143 of 4 thatevaluated paternal education level reported a similarrelationship. Other associated risk factors that were re-ported less consistently included childhood illnesses, 36,40

born late in the family birth order, 42 family size, 39 olderparents 39 or younger mother 43 at birth, and low socio-economic status (SES) or minority race. 40 One study thatevaluated history of asthma found no association withspeech and language delay. 39

The 7 studies that assessed risk in nonEnglish-speak-


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TABLE 3 Instruments Usedin StudiesInstrument Abbreviation Components Authors (y)

Bayley Infant NeurodevelopmentalScreenera

BINS Assesses 4 areas: (1) neurological function/intactness; (2)receptive function; (3) expressive function; and (4)cognitive processes

Macias et al62 (1998)

Clinical Adaptive Test/Clinical LinguisticAuditory Milestone Scale

CAT/CLAMS Includes psychometrics and speech and languagemilestones; CAT: 19 age sets with 12 instruments and57 items for visual motor skills; CLAMS: 19 age setswith 3 instruments up to 24 mo and 4 instrumentsafter 24 mo; includes 43 items for language skills

Clark et al58 (1995)

Denver Developmental Screening Test-IIa

DDST II Domains include (1) language; (2) ne motor-adaptive;(3) personal-social; and (4) gross motor

Glascoe and Byrne57 (1993)

Developmental Prole-IIa DP-II 5 subsets: (1) physical; (2) self-help; (3) social; (4)academic; and (5) communication

Glascoe and Byrne57 (1993)

Early Language Milestone Scale 41 items covering 4 areas: (1) auditory expressive; (2)auditory receptive; (3) visual expressive; and (4) visualreceptive

Coplan et al30 (1982); Black etal55 (1988); Walker et al68

(1989)Fluharty Preschool Speech and

Language Screening Test35 items separated into 3 sections (AC) including

identication of 15 common objects (phoneme),nonverbal responses to 10 sentences (syntax), andimitation of 10 1-sentence picture descriptions; assessidentication, articulation, comprehension, and

repetition

Blaxley et al65 (1983); Sturner etal53 (1993); Allen and Bliss69

(1987)

Hackney Early Language Screening Test 20-item test in 7 sections: (1) comprehension: followinginstructions to manipulate toys; (2) expression: testermanipulates toys and asks child questions about this;(3) comprehension: following instructions for placingtoys; (4) comprehension: child chooses picture from 3options; (5) expression: child answers question aboutpictures; (6) expression: child names objects; and (7)comprehension: child chooses picture from 4 options

Dixon et al54 (1988); Law67

(1994)

Language Development Survey LDS 310 words arranged in 14 semantic categories; parentsindicate which words their child has spoken anddescribe word combinations of 2 words that theirchild has used

Klee et al59 (1998); Klee et al60

(2000); Rescorla and Alley61

(2001)

Levett-Muir Language Screening Test Test is divided into 6 sections: (1) comprehension: childis asked to pick toys from group; (2) vocabulary: childsability to name the toys; (3) comprehension: usingpictures, child is required to respond to questions; (4)vocabulary: childs ability to name whats in thepictures; (5) comprehension and representation:childs ability to answer what and who questions;and (6) overall: child is asked to explain the detailedcomposite picture

Levett and Muir64 (1983)

Parent Evaluation of DevelopmentalStatus

PEDS 2 questions for parents to elicit concerns in general andspecic areas; other items determine reasons forparents concerns

Glascoe56 (1991)

Parent Language Checklista PLC 12 questions for parents about their childs receptive andexpressive language including 1 question forassessing hearing problems

Burden et al11 (1996)

Pediatric Language AcquisitionScreening Tool for Early Referral

PLASTER Communication development milestones by age with 7individual areas; each area contains 10 questions (5relate to receptive language and 5 to expressivelanguage)

Sherman et al52 (1996)

Screening Kit of LanguageDevelopment

SKOLD Vocabulary comprehension, story completion, sentencecompletion, paired-sentence repetition with pictures,individual sentence repetition with pictures,individual sentence repetition without pictures, andauditory comprehension of commands

Bliss and Allen66 (1984)

Sentence Repetition Screening Test SRST 15 sentences repeated 1 at a time by the child afterdemonstration by the tester

Sturner et al71 (1996)

Structured Screening Test 20 questions covering both expressive and receptivelanguage skills

Laing et al63 (2002)

Test for Examining ExpressiveMorphology

TEEM 54 items targeting a variety of morphosyntacticstructures using a sentence-completion task

Merrell and Plante70 (1997)

a Speech and language are part of a broader screening instrument.


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ing populations included case-control, 47 cross-section-al, 45 prospective-cohort, 4851 and concurrent-compari-son 46 designs. Studies evaluated several types of delayincluding vocabulary, 46 speech, 45 stuttering, 47 lan-guage, 4851 and learning. 4951 Signicant associations werereported in the 2 studies that evaluated family history 45,48

and 1 of 2 studies that evaluated male gender. 51 Three of4 nonEnglish-language studies, including a cohort of

8000 children in Finland, 51 reported signicant associ-ations with perinatal risk factors such as prematurity, 50,51

birth difculties, 45 low birth weight, 50,51 and sucking hab-its. 45 An association with perinatal risk factors was notfound in the 1 English-language study that examinedlow birth weight. 43 Other associated risk factors thatwere reported less consistently include parental educa-tion level 49,50 and family factors such as size and over-

TABLE 4 Studies of Screening Instruments for Children Up to 2 Years OldAuthors (y) N Instrument Reference Standard Speech and Language

Domains

Under 5 min to administerGlascoe56 (1991) 157 Parent Evaluation of Developmental

StatusClinical assessment Expressive language,

articulation

Coplan et al30 (1982) 191 Early Language Milestone Scale Clinical assessment Expressive and receptivelanguage

Black et al55 (1988) 48 Early Language Milestone Scale Receptive-Expressive EmergentLanguage Scale, BayleyScales of InfantDevelopment

Expressive and receptivelanguage

510 min to administerGlascoe and Byrne57 (1993)

Study 189 Developmental Prole II Battery of measures Fine motor adaptive, personal

social, gross motor, andlanguage

Sherman et al52 (1996) 173 Pediatric Language AcquisitionScreening Tool for Early Referral

Early Language Milestone Scale Expressive and receptivelanguage

10 min to administerMacias et al62 (1998) 78 Bayley Infant Neurodevelopmental

ScreenerBayley Scales of Infant

Development IIExpressive and receptive

language

Klee et al59 (1998) 306 Language Development Survey Infant Mullen Scales of EarlyLearning

Expressive vocabulary

Klee et al60 (2000) 64 Language Development Survey Infant Mullen Scales of EarlyLearning

Expressive vocabulary

Rescorla and Alley61 (2001) 422 Language Development Survey Bayley Scales of InfantDevelopment, Stanford-Binet, ReynellDevelopmental LanguageScales

Expressive vocabulary: delay 1,30 words and no word

combinations; delay 2,30 words or no word

combinations; delay 3,50 words or no word

combinations

Clark et al58 (1995) 99 Clinical Linguistic and AuditoryMilestone Scale

Sequenced Inventory of CommunicationDevelopment

Syntax, pragmatics

Glascoe and Byrne57 (1993)Study 2

89 Denver Developmental Screening Test II (communicationcomponents)

Battery of measures Physical, self-help, social,academic, andcommunication


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crowding. 50,51 These studies did not nd associations withthe mothers stuttering or speaking style or rate, 47 themothers age, 51 or child temperament. 46

Key Questions 2b and 2c: What Are Screening Techniquesand How Do They Differ by Age? What Is the Accuracy of Screening Techniques and How Does It Vary by Age?A total of 22 articles that reported performance charac-teristics of 24 evaluations met inclusion criteria. 33 The

studies used several different standardized and non-standardized instruments (Table 3), although manywere not designed specically for screening purposes.Results of the instruments were compared with those ofa variety of reference standards, and no gold standardwas acknowledged or used across studies, which limitedcomparisons between them.

The studies provided limited demographic details ofsubjects, and most included predominantly white chil-

TABLE 4 ContinuedSubjects Setting Screener Sensitivity, % Specicity, % Study Quality

Rating

From outpatient clinic orprivate practice; 78% white;54% male; 677 mo

Clinic Doctoral students in psychologyor special education

72 83 Good

From private practices andpediatric outpatients of hospital; 80% white; 50%male; 036 mo

Physicians ofce Medical students 97 93 Fair

From low socioeconomicgroups; 822 mo

Large pediatric clinic,university teachinghospital

Not reported 83 100 Poor

From 5 day care centers; 52%male; 770 mo

Day care centers Psychologist 73 76 Fair

123 high-risk infants; 50normal controls; 336 mo

High risk: neonataldevelopmentalfollow-up clinic;

control: speechand hearing clinic

Speech and languagepathologist and graduatestudents

53 86 Fair

Randomly selected from thosepresenting for routineneonatal high-risk follow-up; 54% male; 62% black;623 mo

Physicians ofce Developmental pediatrician 73 (using middle-cut scores)

66 (using middle-cut scores)

Fair

Toddlers turning 2 y old duringthe study in Wyoming; 52%male; 2426 mo

Home Parent 91 87 Good-Fair

Children turning 2 y in aspecic month in an area of Wyoming

Home Parent 83 (at age 2); 67 (atage 3)

97 (at age 2); 93 (atage 3)

Fair

Toddlers in 4 townships of Delaware County, PA,turning 2 y old during thestudy

Home Parent and research assistant Delay 1: 70 (Bayley) ,52 (Binet), 67(Reynell); delay 2:75 (Bayley), 56(Binet), 89(Reynell); delay 3:80 (Bayley), 64(Binet), 94(Reynell)

Delay 1: 99 (Bayley),98 (Binet), 94(Reynell); delay 2:96 (Bayley), 95(Binet), 77(Reynell); delay 3:94 (Bayley), 94(Binet), 67(Reynell);

Fair

Infants turning 1 or 2 y oldduring study; 55% male;036 mo

Home or school forthe deaf

Speech and languagepathologist

Receptive: 83 (1424 mo), 68 (2536 mo);expressive: 50(1424 mo), 88(2536 mo)

Receptive: 93 (1424 mo), 89 (2536 mo);expressive: 91(1424 mo), 98(2536 mo)

Fair

Children from 5 day carecenters; 52% male: 770 mo

Day care centers Psychologist 22 86 Fair


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dren with similar proportions of boys and girls. Onestudy enrolled predominantly black children 52 and an-other children from rural areas. 53 Study sizes rangedfrom 25 subjects 54 to 2590 subjects. 11 Testing was con-ducted in general health clinics, specialty clinics, day

care centers, schools, and homes by pediatricians,nurses, speech and language specialists, psychologists,health visitors, medical or graduate students, teachers,parents, and research assistants. Studies are summarized below by age categories according to the youngest agesincluded, although many studies included children inoverlapping age categories.

Ages 0 to 2 YearsEleven studies from 10 publications used instruments

that take 10 minutes to administer for children up to 2years old, including the Early Language MilestoneScale, 30,55 Parent Evaluation of Developmental Status, 56

Denver Developmental Screening Test II (language com-ponent), 57 Pediatric Language Acquisition ScreeningTool for Early Referral, 52 Clinical Linguistic and AuditoryMilestone Scale, 58 Language Development Survey, 5961

Development Prole II, 57 and the Bayley Infant Neuro-

developmental Screener 62 (Table 4). Of these studies, 6tested expressive and/or receptive language, 30,52,55,57,62 3tested expressive vocabulary, 5961 1 tested expressive lan-guage and articulation, 56 and 1 tested syntax and prag-matics. 58

For the 10 fair- and good-quality studies that pro-vided data to determine sensitivity and specicity, sen-sitivity ranged from 22% to 97% and specicity rangedfrom 66% to 97%. 30,52,5662 Four studies reported sensi-tivity and specicity of 80% when using the EarlyLanguage Milestone Scale, 30 the Language DevelopmentSurvey, 59,60 and the Clinical Linguistic and Auditory

TABLE 5 Studiesof Screening Instruments for Children 2 to 3 Years OldAuthors (y) N Instrument Reference Standard Speech and Language

Domains

5 min to administerBurden et al11

(1996)2590 Parent Language Checklist Clinical judgement Expressive and receptive

languageLaing et al63

(2002)376 Structured Screening Test Reynel l Developmental Language

ScalesExpressive and receptive

language

Levett and Muir64

(1983)140 Levett-Muir Language

Screening TestReynell Developmental Language

Scales, Goldman-Fristoe Test of Articulation, LanguageAssessment and RemediationProcedure

Receptive language,phonology, syntax

Sturner53 (1993)Study 1

279 Fluharty Preschool Speechand LanguageScreening Test

Arizona Articulation ProciencyScale Revised, Test of LanguageDevelopment Primary

Expressive and receptivelanguage, articulation

Sturner et al53

(1993) Study 2421 Fluharty Preschool Speech

and LanguageScreening Test

Test for Auditory Comprehensionof Language Revised, Templin-Darley Test of Articulation

Expressive and receptivelanguage, articulation

10 min to administerLaw67 (1994) 1205 Hackney Early Language

Screening Test

Reynell Developmental Language

Scales

Expressive language

Blaxley65 (1983) 90 Fluharty Preschool Speechand LanguageScreening Test

Developmental Sentence Scoring Expressive and receptivelanguage, articulation

Bliss and Allen66

(1984)602 Screening Kit of Language

DevelopmentSequenced Inventory of

Communication DevelopmentExpressive and receptive

language

Dixon et al54(1988)

25 Hackney Early LanguageScreening Test

Clinical judgement Expressive language

Walker et al68

(1989)77 Early Language Milestone

ScaleSequenced Inventory of

Communication DevelopmentExpressive and receptive

language


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Milestone Scale. 58 The study of the Clinical Linguisticand Auditory Milestone Scale also determined sensitivityand specicity by age and reported higher sensitivity/specicity at 14 to 24 months of age (83%/93%) than 25to 36 months of age (68%/89%) for receptive function

but lower sensitivity/specicity at 14 to 24 months of age(50%/91%) than 25 to 36 months of age (88%/98%) forexpressive function. 58 A study that tested expressive vo-cabulary by using the Language Development Surveyindicated higher sensitivity/specicity at 2 years of age(83%/97%) than at 3 years of age (67%/93%). 60

Ages 2 to 3 YearsTen studies in 9 publications used instruments that

take 10 minutes to administer for children aged 2 to 3,including the Parent Language Checklist, 11 StructuredScreening Test, 63 Levett-Muir Language Screening Test, 64

Fluharty Preschool Speech and Language Screening

Test, 53,65 Screening Kit of Language Development, 66

Hackney Early Language Screening Test, 54,67 and EarlyLanguage Milestone Scale 68 (Table 5). All the studiestested expressive and/or receptive language. 11,53,54,6368 Inaddition, 3 studies tested articulation, 53,65 and 1 studied

syntax and phonology. 64For the 8 fair- and good-quality studies that provided

data to determine sensitivity and specicity, sensitivityranged from 17% to 100% and specicity ranged from45% to 100%. Two studies reported sensitivity and spec-icity of 80% when using the Levett-Muir LanguageScreening Test 64 and the Screening Kit of Language De-velopment. 66 The study of the Screening Kit of LanguageDevelopment reported comparable sensitivity/specicityat 30 to 36 months (100%/98%), 37 to 42 months(100%/91%), and 43 to 48 months of age (100%/93%). 66

TABLE 5 ContinuedSubjects Setting Screener Sensitivity, % Specicity, % Study Quality

Rating

All children turning 36 mo;52% male; 41% urban

Home (mailed) Parent 87 45 Good

Children from 2 low-SEScounties in London;mean age: 30 mo

Physicians ofce Health visitor 66 (severe); 54 (needstherapy)

89 (severe); 90 (needstherapy)

Fair

Private practicepopulation; 3440 mo

Physicians ofce Medical practitioners 100 100 Fair

46% male; 74% white;86% rural; 2472 mo

Preschool Teacher 43 (speech and language);74 (speech); 38(language)

82 (speech and language);96 (speech); 85(language)

Fair

52% male; 75% white;2472 mo

Preschool Teacher 31 (speech and language);43 (speech); 17(language)

93 (speech and language);93 (speech); 97(language)

Fair

Children attending routine

developmentalcheckups; mean age: 30mo

Home Health visitor 98 69 Good-Fair

Children referred forspeech and/or languageassessment andintervention andcontrols; 2472 mo

Speech and hearingclinic in westernOntario

Clinician 36 (10th percentile); 30(25th percentile)

95 (10th percentile); 100(25th percentile)

Fair

From day care centers inDetroit, MI; 3048 mo

Speech andlanguage hearingclinic, day-carecenter,physicians ofce,educational andhealth facilities

Paraprofessionals and speechand language pathologists

100 (3036 mo); 100 (3742 mo); 100 (4348 mo)

98 (3036 mo); 91 (3742mo); 93 (4348 mo)

Fair

Pilot study at 1 clinicsetting in Hackney;mean age: 30 mo

Physicians ofce Health visitor 95 94 Poor

All children attending astudy clinic; mean age:36 mo

Clinic Speech and languagepathologist

0 (012 mo); 100 (1324mo); 100 (2536 mo)

86 (012 mo); 60 (1324mo); 75 (2536 mo)

Poor


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Ages 3 to 5 YearsThree studies used instruments that take 10 min-

utes to administer, including the Fluharty PreschoolSpeech and Language Screening Test, 69 Test for Exam-ining Expressive Morphology, 70 and the Sentence Repe-tition Screening Test 71 (Table 6). Of these studies, 2tested expressive and receptive language and articula-

tion, 69,71 and 1 tested expressive vocabulary and syntax. 70The 2 fair-quality studies reported sensitivity rangingfrom 57% to 62% and specicity ranging from 80% to95%. 66,69,71

Systematic Review A Cochrane systematic review of 45 studies, including

most of the studies cited above, summarized the sensi-tivity and specicity of instruments that take 30 min-utes to administer. 34 Sensitivity of the instruments fornormally developing children ranged from 17% to100% and for children from clinical settings it rangedfrom 30% to 100%. Specicity ranged from 43% to100% and 14% to 100%, respectively. Studies consid-ered to be of higher quality tended to have higher spec-icity than sensitivity ( t 4.41; P .001); however,high false-positive and false-negative rates were re-ported often. 34

Key Question 2d: What Are the Optimal Ages and Frequency for Screening?No studies addressed this question.

Key Question 3: What Are the Adverse Effects of Screening?No studies addressed this question. Potential adverseeffects include false-positive and false-negative results.False-positive results can erroneously label children withnormal speech and language as impaired, potentiallyleading to anxiety for children and families and addi-tional testing and interventions. False-negative resultswould miss identifying children with impairment, po-tentially leading to progressive speech and language de-lay and other long-term effects including communica-tion, social, and academic problems. In addition, oncedelay is identied, children may be unable to accessservices because of unavailability or lack of insurancecoverage.

Key Question 4: What Is the Role of Enhanced Surveillance byPrimary Care Clinicians?No studies addressed this question.

Key Question 5: Do Interventions for Speech and LanguageDelay Improve Speech and Language Outcomes?Twenty-ve RCTs in 24 publications met inclusion cri-teria, including 1 rated good, 72 13 rated fair, 7385 and 11rated poor quality 77,8695 (Table 7). Studies were consid-ered to be of poor quality if they reported importantdifferences between intervention and comparison

groups at baseline, did not use intention-to-treat analy-sis, no method of randomization was reported, or therewere 10 subjects in the intervention or comparisongroups. Limitations of studies, in general, include smallnumbers of participants (only 4 studies enrolled 50subjects), lack of consideration of potential confounders,and disparate methods of assessment, intervention, and

outcome measurement. As a result, conclusions abouteffectiveness are limited. Although children in the stud-ies ranged from 18 to 75 months old, most studies in-cluded children 2 to 4 years old, and their results do notallow for determination of the optimal ages of interven-tion.

The studies evaluated the effects of individual orgroup therapy directed by clinicians and/or parents thatfocused on specic speech and language domains. Thesedomains included expressive and receptive language,articulation, phonology, lexical acquisition, and syntax.Several studies used established approaches to therapy

such as the Ward Infant Language Screening Test, As-sessment, Acceleration, and Remediation program 96 andthe Hanen principles. 78,79,85,93 Others used more theoret-ical approaches such as focused stimulation, 78,79,86,87,93 au-ditory discrimination, 83,90 imitation or modeling proce-dures, 76,92 auditory processing or work mapping, 85 andplay narrative language. 80,81 Some interventions focusedon specic words and sounds, used unconventionalmethods, or targeted a specic decit.

Outcomes were measured by subjective reports fromparents 77,78,80,85 and by scores on standardized instru-ments such as the Reynell Expressive and Receptive

Scales,74,77

the Preschool Language Scale,72,75,85

and theMacArthur Communicative Development Invento-ries. 80,93 The most widely used outcome measure wasmean-length utterances, used by 6 studies. 73,75,77,80,85

Studies rated as good or fair quality are described below by age categories according to the youngest agesincluded, although many studies included children inoverlapping categories

Ages 0 to 2 YearsNo studies examined this age group exclusively, al-though 1 good-quality study enrolled children who were18 to 42 months old. 72 The clinician-directed, 12-monthintervention consisted of 10-minute weekly sessions fo-cusing on multiple language domains, expressive andreceptive language, and phonology. Treatment for re-ceptive auditory comprehension lead to signicant im-provement for the intervention group compared withthe control group; however, results did not differ be-tween groups for several expressive and phonology out-comes. 72

Ages 2 to 3 YearsOne good 72 and 6 fair-quality 7780,84,85 studies evaluatedspeech and language interventions for children who


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were 2 to 3 years old. The studies reported improvementon a variety of communication domains including clini-cian-directed treatment for expressive and receptive lan-guage, 80 parent-directed therapy for expressive delay, 77,78

and clinician-directed receptive auditory comprehen-sion. 72 Lexical acquisition was improved with both clini-cian-directed 84,91 and group therapy approaches. 84 In 3

studies, there were no between-group differences forclinician-directed expressive 72,85 or receptive languagetherapy, 72,85 parent-directed expressive or receptive ther-apy, 85 or parent-directed phonology treatment. 79

Ages 3 to 5 YearsFive fair-quality studies reported signicant improve-ments for children who were 3 to 5 years old and un-dergoing interventions compared with controls, 73,74,76,81,82

whereas 2 studies reported no differences. 75,83 Bothgroup-based 81 and clinician-directed 74 interventionswere successful in improving expressive and receptive

competencies.

Systematic Review A Cochrane systematic review included a meta-analysisusing data from 25 RCTs of interventions for speech andlanguage delay for children up to adolescence. 35 Twenty-three of these studies 7292,95 also met criteria for this re-view and are included in Table 7, and 2 trials wereunpublished. The review reported results in terms ofstandard mean differences (SMDs) in scores for a number of domains (phonology, syntax, and vocabulary).Effectiveness was considered signicant for both the

phonological (SMD: 0.44; 95% condence interval [CI]:0.010.86) and vocabulary (SMD: 0.89; 95% CI: 0.211.56) interventions. Less effective was the receptive in-tervention (SMD: 0.04; 95% CI: 0.640.56), and re-sults were mixed for the expressive syntax intervention(SMD: 1.02; 95% CI: 0.042.01). When interventionswere comparable in duration and intensity, there wereno differences between interventions when they wereadministered by trained parents or clinicians for expres-sive delays. Use of normal-language peers as part of theintervention strategy also proved benecial. 81

Key Question 6: Do Interventions for Speech and LanguageDelay Improve Other NonSpeech andLanguage Outcomes?Four good- 72 or fair-quality 80,81,85 intervention studies in-cluded functional outcomes other than speech and lan-guage. Increased toddler socialization skills, 80 improvedchild self-esteem, 85 and improved play themes 81 werereported for children in intervention groups in 3 studies.Improved parent-related functional outcomes includeddecreased stress 80 and increased positive feelings towardtheir children. 85 Functional outcomes that were studied but did not show signicant treatment effects includedwell-being, levels of play and attention, and socializationskills in 1 study. 72 T

A B L E 6

S t u d i e s o f S c r e e n i n g I n s t r u m e n

t s f o r C h i l d r e n 3 t o 5 Y e a r s O l d

A u t h o r s ( y )

N

I n s t r u m e n t

R e f e r e n c e S t a n d a r d

S p e e c h a n d L a n g u a g e

D o m a i n s

S u b j e c t s

S e t t i n g

S c r e e n e r

S e n s i t i v i t y

, %

S p e c i c i t y

, %

S t u d y

Q u a l i t y

R a t i n g

1 0 m i n t o a d m i n i s t e r

A l l e n a n d B l i s s 6 9

( 1 9 8 7 )

1 8 2 F l u h a r t y P r e s c h o o l S p e e c h

a n d L a n g u a g e

S c r e e n i n g T e s t

S e q u e n c e d I n v e n t o r y o f

C o m m u n i c a t i o n

D e v e l o p m e n t

E x p r e s s i v e

a n d r e c e p t i v e

l a n g u a g e , a r t i c u l a t i o n

F r o m d a y c a r e

p r o g r a m s ; 3 6

4 7 m o

C l i n i c

S p e e c h a n d l a n g u a g e

p a t h o l o g i s t s

6 0

8 0

F a i r

S t u r n e r e t a l 7 1 ( 1 9 9 6 ) 7 6

S e n t e n c e R e p e t i t i o n

S c r e e n i n g T e s t


S c r e e n i n g Q u e s t i o n n a i r e

R e c e p t i v e a n d

e x p r e s s i v e l a n g u a g e

,

a r t i c u l a t i o n

C h i l d r e n r e g i s t e r i n g f o r

k i n d e r g a r t e n ; 4

8 %

m a l e ; 6 5 % w h i t e ;

5 4 6

6 m o

S c h o o l

N o n s p e c i a l i s t s o r s c h o o l

s p e e c h a n d l a n g u a g e


6 2 ( r e c e p t i v e a n d

e x p r e s s i v e ) ; 5 7

( a r t i c u l a t i o n )

9 1 ( r e c e p t i v e a n d

e x p r e s s i v e ) ; 9 5

( a r t i c u l a t i o n )

F a i r

M e r r e l l a n d P l a n t e 7 0

( 1 9 9 7 )

4 0

T e s t f o r E x a m i n i n g

E x p r e s s i v e M o r p h o l o g y

K a u f m a n A s s e s s m e n t B a t t e r y

f o r C h i l d r e n , S t r u c t u r e d

P h o t o g r a p h i c E x p r e s s i o n

L a n g u a g e T e s t I I

E x p r e s s i v e

v o c a b u l a r y

,

s y n t a x

2 0 i m p a i r e d a n d 2 0

u n i m p a i r e d ; 5 2 %

m a l e 7 3 % w h i t e ;

4 8 6

7 m o

S c h o o l o r c l i n i c S p e e c h a n d l a n g u a g e


9 0

9 5

P o o r


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T A B L E 7

C o n t i n u e d

A u t h o r s ( y )


D o m a i n s

N ( N o

. o f

G r o u p s )

A g e , m o

I n t e r v e n t i o n s

S p e e c h a n d L a n g u a g e O u t c o m e s

F u n c t i o n a n d H e a l t h

O u t c o m e s

S t u d y Q u a l i t y

R a t i n g

w k f o r 3 m o v s c l a s s r o o m

i n t e r v e n t i o n f o r 3 6 0 m i n /

w k f o r 3 m o

w o r d s a t h o m e i n c l a s s r o o m g r o u p

v s i n d i v i d u a l g r o u p

G i r o l a m e t t o e t

a l 7 9 ( 1 9 9 7 )

L e x i c a l a c q u i s i t i o n a n d

p h o n o l o g y

2 5 ( 2 )

2 3 3

3

P a r e n t - d

i r e c t e d i n d i v i d u a l

t h e r a p y f o r e i g h t 1 5 0 -

m i n s e s s i o n s a n d 3 h o m e

s e s s i o n s f o r 1 1 w k v s

n o n e

I m p r o v e d l e v e l o f v o c a l i z a t i o n s a n d

i n v e n t o r y o f c o n s o n a n t s f o r

i n t e r v e n t i o n g r o u p v s c o n t r o l ; n o

d i f f e r e n c e s i n t h e n u m b e r o f

v o c a l i z a t i o n s

N o t r e p o r t e d

F a i r

3 t o 5 y

B a r r a t t e t a l 7 4

( 1 9 9 2 )

E x p r e s s i v e a n d r e c e p t i v e

l a n g u a g e

3 9 ( 2 )

3 7 4

3

C l i n i c i a n - d

i r e c t e d

i n t e r a c t i v e l a n g u a g e

t h e r a p y f o r 4 0 m i n / w k

f o r 6 m o ( t r a d i t i o n a l

g r o u p ) v s 4 0 m i n f o r 4

d a y s / w k f o r 3 w k i n t w o

3 - m o b l o c k s ( i n t e n s i v e

g r o u p )

I m p r o v e d e x p r e s s i o n s c o r e o n

R e y n e l l s c a l e f o r i n t e n s i v e g r o u p v s

w e e k l y ( o r t r a d i t i o n a l ) t h e r a p y

g r o u p ; n o d i f f e r e n c e i n

c o m p r e h e n s i o n s c o r e s

, b o t h w e r e

i m p r o v e d


F a i r

C o u r t r i g h t a n d

C o u r t r i g h t 7 6

( 1 9 7 9 )

E x p r e s s i v e l a n g u a g e

3 6 ( 3 )

4 7 8

3

3 c l i n i c i a n - d i r e c t e d

a p p r o a c h e s a r e

c o m p a r e d f o r 5 m o :

m i m i c r y

, c l i n i c i a n

m o d e l i n g , 3 r d - p e r s o n

m o d e l i n g f o r 5 m o

I n c r e a s e d n u m b e r o f c o r r e c t

r e s p o n s e s i n m o d e l i n g g r o u p s v s

m i m i c r y g r o u p


F a i r

R o b e r t s o n a n d

W e i s m e r 8 1

( 1 9 9 7 )


l a n g u a g e

3 0 ( 3 )

4 4 6

1

2 c l i n i c i a n - d i r e c t e d p l a y

g r o u p s w i t h l a n g u a g e

i m p a i r m e n t s ( t r e a t m e n t

v s c o n t r o l ) w i t h n o r m a l

p e e r s f o r 2 0 m i n / w k f o r 3

w k

M o r e w o r d s u s e d

, g r e a t e r v e r b a l

p r o d u c t i v i t y

, m o r e l e x i c a l d i v e r s i t y

,

a n d m o r e u s e o f l i n g u i s t i c m a r k e r s

b y n o r m a l p e e r p l a y g r o u p ( n o t

n o r m a l g r o u p , t r e a t m e n t g r o u p

w i t h l a n g u a g e i m p a i r m e n t ) v s

c o n t r o l

P l a y - t

h e m e r e l a t e d a c t s

i n c r e a s e d f o r t h e n o r m a l

p e e r p l a y g r o u p ( n o t

n o r m a l g r o u p , t r e a t m e n t

g r o u p w i t h l a n g u a g e

i m p a i r m e n t )

F a i r

G l o g o w s k a e t a l 7 2

( 2 0 0 2 )


l a n g u a g e a n d

p h o n o l o g y

1 5 9 ( 2 )

4 2


i r e c t e d f o r 1 2 m o

v s n o n e

I m p r o v e d r e c e p t i v e l a n g u a g e i n

i n t e r v e n t i o n g r o u p v s c o n t r o l ; n o

d i f f e r e n c e s b e t w e e n g r o u p s f o r 4

o t h e r m e a s u r e s

I m p r o v e d f a m i l y r e s p o n s e t o

c h i l d i n i n t e r v e n t i o n

g r o u p

P o o r

A l m o s t a n d

R o s e n b a u m 7 3

( 1 9 9 8 )

P h o n o l o g y

2 6 ( 2 )

3 3 6

1



t h e r a p y f o r t w o 3 0

- m i n

s e s s i o n s / w k f o r 4 m o v s

n o n e

H i g h e r s c o r e s o n 3 o f 4 m e a s u r e s f o r

i n t e r v e n t i o n v s c o n t r o l g r o u p


F a i r

R v a c h e w a n d

N o w a k 8 2 ( 2 0 0 1 )

P h o n o l o g y

4 8 ( 2 )

5 0 ( m e a n )



t h e r a p y 3 0

4 0 m i n / w k

f o r 1 2 w k ; c o m p a r e s

i n t e r v e n t i o n s f o r

p h o n e m e s t h a t d i f f e r

( m o s t - k n o w l e d g e / e a r l y -

d e v e l o p i n g g r o u p v s

I m p r o v e d s c o r e s o n m e a s u r e s f r o m

b a s e l i n e f o r b o t h i n t e r v e n t i o n

g r o u p s ; g r e a t e r i m p r o v e m e n t f o r

m o s t - k n o w l e d g e / e a r l y

-

d e v e l o p i n g p h o n e m e s g r o u p v s

c o m p a r i s o n ( l e a s t - k n o w l e d g e /

l a t e s t - d

e v e l o p i n g ) g r o u p


F a i r


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l e a s t - k n o w l e d g e / l a t e s t -

d e v e l o p i n g g r o u p )

S h e l t o n e t a l 8 3

( 1 9 7 8 )

P h o n o l o g y a n d

a r t i c u l a t i o n

4 5 ( 3 )

2 7 5

5

P a r e n t - d


t h e r a p y f o r 5 m i n p e r d a y

( l i s t e n i n g g r o u p ) v s 1 5

N o i m p r o v e m e n t s f o r i n t e r v e n t i o n

g r o u p s v s c o n t r o l


F a i r

m i n p e r d a y ( r e a d i n g a n d

t a l k i n g g r o u p ) f o r 5 7 d a y s

v s n o n e

F e y e t a l 8 6 ( 1 9 9 4 )

P h o n o l o g y a n d s y n t a x

2 6 ( 3 )

4 4 7

0


i r e c t e d s e s s i o n s

( i n d i v i d u a l a n d g r o u p ) f o r

3 h / w k f o r 2 0 w k v s

p a r e n t - d


f o r 8 h / w k f o r w e e k s 1

1 2 ( i n c l u d e s i n t e n s i v e

p a r e n t t r a i n i n g ) t h e n 4

h / w k f o r w e e k s 1 3

2 0 v s

n o n e

I m p r o v e d g r a m m a t i c a l o u t p u t

( d e v e l o p m e n t a l s e n t e n c e s c o r e s )

f o r b o t h i n t e r v e n t i o n g r o u p s v s

c o n t r o l ; n o s i g n i c a n t d i f f e r e n c e

b e t w e e n g r o u p s f o r p h o n o l o g i c a l

o u t p u t ( p e r c e n t a g e c o n s o n a n t s

c o r r e c t )


P o o r

R e i d a n d

D o n a l d s o n 9 5

( 1 9 9 6 )

P h o n o l o g y

3 0 ( 2 )

4 2 6

6



t h e r a p y f o r 3 0 m i n / w k f o r

6 1 0 w k v s n o n e

I m p r o v e d s c o r e s o n s o m e m e a s u r e s

f r o m b a s e l i n e f o r i n t e r v e n t i o n a n d

c o n t r o l g r o u p s ; n o b e t w e e n - g r o u p

c o m p a r i s o n s r e p o r t e d


P o o r

R u s c e l l o e t a l 8 9

( 1 9 9 3 )

P h o n o l o g y

1 2 ( 2 )

4 9 6

8


i r e c t e d v s

c l i n i c i a n - a n d p a r e n t -

d i r e c t e d i n d i v i d u a l

t h e r a p y f o r 1 2 0 m i n / w k

f o r 8 w k

I m p r o v e d s c o r e s o n m e a s u r e s f r o m

b a s e l i n e f o r b o t h i n t e r v e n t i o n

g r o u p s ; n o b e t w e e n - g r o u p

c o m p a r i s o n s r e p o r t e d


P o o r

R v a c h e w 9 0 ( 1 9 9 4 )

P h o n o l o g y

2 7 ( 3 )

4 2 6

6



t h e r a p y f o r 4 5 m i n / w k f o r

6 w k ; c o m p a r e s 3 g r o u p s

l i s t e n i n g t o d i f f e r e n t s e t s

o f w o r d s

I m p r o v e d s c o r e s o n m e a s u r e s f o r 2

i n t e r v e n t i o n g r o u p s v s t h i r d g r o u p


P o o r

C o l e a n d D a l e 7 5

( 1 9 8 6 )

S y n t a x

4 4 ( 2 )

3 8 6

9



d i r e c t i v e a p p r o a c h v s

i n t e r a c t i v e a p p r o a c h f o r

6 0 0 m i n / w k f o r 8 m o

I m p r o v e d s c o r e s o n 6 o f 7 m e a s u r e s

f r o m b a s e l i n e f o r b o t h i n t e r v e n t i o n

g r o u p s ; n o s i g n i c a n t d i f f e r e n c e s

b e t w e e n g r o u p s


F a i r

F e y e t a l 9 2 ( 1 9 9 3 )

,

r s t p h a s e

S y n t a x

2 9 ( 3 )

4 4 7

0



( i n d i v i d u a l a n d g r o u p ) f o r

3 h / w k f o r 2 0 w k v s

p a r e n t - d


f o r 8 h / w k f o r w e e k s 1

1 2 ( i n c l u d e s i n t e n s i v e

p a r e n t t r a i n i n g ) t h e n 4

h / w k f o r w e e k s 1 3

2 0 v s

n o n e

I m p r o v e d s c o r e s o n 3 o f 4 m e a s u r e s

f o r b o t h i n t e r v e n t i o n g r o u p s v s

c o n t r o l ; n o d i f f e r e n c e s b e t w e e n

i n t e r v e n t i o n g r o u p s


P o o r

F e y e t a l 8 7 ( 1 9 9 7 )

,

s e c o n d p h a s e

S y n t a x

2 8 ( 3 )

4 4 7

0


i r e c t e d v s p a r e n t -

d i r e c t e d v s n o n e f o r 5 m o

c o n t i n u i n g f r o m p r i o r

s t u d y

I m p r o v e d s o m e d e v e l o p m e n t a l

s e n t e n c e s c o r e s f r o m b a s e l i n e i n

b o t h i n t e r v e n t i o n g r o u p s v s

c o n t r o l ; n o b e t w e e n - g r o u p

c o m p a r i s o n s r e p o r t e d e x c e p t t h a t


P o o r


8/10/2019 e298.pdf

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Key Question 7: Does Improvement in Speech and LanguageOutcomes Lead to Improved Additional Outcomes?No studies addressed this question.

Key Question 8: What Are the Adverse Effects of Interventions?No studies addressed this question. Potential adverse

effects of treatment programs include the impact of timeand cost of interventions on clinicians, parents, children,and siblings. Loss of time for play and family activities,stigmatization, and labeling may also be potential ad-verse effects.

CONCLUSIONS

Studies are not available that address the overarchingkey question about the effectiveness of screening (keyquestion 1), adverse effects of screening (key question3), the role of enhanced surveillance in primary care(key question 4), long-term effectiveness of interven-

tions on nonspeech and language outcomes for chil-dren identied with delay (key question 7), and adverseeffects of interventions (key question 8). No studies havedetermined the optimal ages and frequency for screen-ing (key question 2d). Relevant studies are availableregarding the use of risk factors for screening (key ques-tion 2a), techniques for screening (key questions 2b and2c), and effectiveness of interventions on short-termspeech and language and nonspeech and language out-comes for children identied with delay (key questions 5and 6).

The use of risk factors for selective screening has not been evaluated, and a list of specic risk factors to guideprimary care physicians has not been developed ortested. Sixteen studies about potential risk factors forspeech and language delay in children enrolled hetero-geneous populations, had dissimilar inclusion and exclu-sion criteria

e298.pdf

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