Putting Prevention into Practice
An Evidence-Based Approach
Screening for Speech and Language Delay in Preschool Children
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Am Fam Physician. 2006 Oct 15;74(8):1373-1374.
This clinical content conforms to AAFP criteria for evidence-based continuing medical education (EB CME). EB CME is clinical content presented with practice recommendations supported by evidence that has been systematically reviewed by an AAFP-approved source. The practice recommendations in this activity are available at http://www.ahrq.gov/clinic/uspstf/uspschdv.htm.
R.F. brings her three-year-old daughter in for a routine well-child examination. R.F. says that she is not concerned about her daughter’s development, but that her friend’s preschooler is being evaluated for a possible speech delay. She asks whether her daughter needs to be checked for this as well.
Case Study Questions
Based on information from the U.S. Preventive Services Task Force (USPSTF), which one of the following statements is correct in relation to this patient’s care?
A. There is good evidence that routinely using brief, formal screening instruments in primary care can accurately identify speech and language delay in preschool children.
B. Evidence is insufficient to recommend for or against routine use of brief, formal instruments in primary care to detect speech and language delay in preschool children.
C. The effectiveness of speech and language interventions on long-term health outcomes has been well demonstrated.
D. Many studies provide good evidence that there are additional benefits to screening and treating children who would not be identified by addressing clinical or parental concerns.
E. There is good evidence that this child may experience harms from screening for speech and language delays.
Which of the following statements about risk factors for speech and language delay is/are correct?
A. Children born post-dates are at an increased risk of speech and language delay.
B. Girls are more likely than boys to have speech and language delay.
C. Low–birth-weight infants are at increased risk of speech and language delay.
D. Children born to young mothers are at an increased risk of speech and language delay.
E. A family history of speech and language delay does not affect a child’s risk of developing the problem.
You note that the patient is reaching all her developmental milestones. Which of the following statements is/are accurate and appropriate to share with R.F.?
A. Speech and language delays always exist together.
B. Speech and language development is an early indicator of a child’s overall development.
C. Speech and language delay in preschool children rarely persists into the school years.
D. Parental concerns are important in identifying children with speech and language delay.
1. The correct answer is B. The USPSTF found insufficient evidence that brief, formal speech and language development screening instruments suitable for use in primary care can accurately identify children who would benefit from further evaluation and intervention. This refers to screening children in the general population as opposed to specific groups of children who already have been identified at higher-than-average risk of speech and language delay, including children with medical problems such as hearing deficits or craniofacial abnormalities.
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 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, nor have any studies addressed the potential harms of screening or interventions for speech and language delays (e.g., labeling, parental anxiety, unnecessary evaluation and intervention).
2. The correct answer is C. As noted above, specific groups are already at higher-than-average risk of speech and language delay. 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 physicians in selective screening. The most consistently reported risk factors, however, include perinatal factors such as prematurity and low birth weight, male sex, and a family history of speech and language delay. Other risk factors that are reported less consistently include levels of parental education, specific childhood illnesses, birth order, and larger family size.
3. The correct answers are B and D. Speech refers to the mechanics of oral communication; language encompasses the understanding, processing, and production of communication. Speech and language delays can exist either together or separately. Speech and language development is considered a useful early indicator of a child’s overall development and cognitive abilities. Children five years of age or younger whose speech and language delays are untreated may exhibit diminished reading skills in grade school, poor verbal and spelling skills, behavior problems, and impaired psychosocial adjustment. In turn, these problems may lead to overall academic underachievement and lower IQ scores that may persist into young adulthood.
Clinical and parental concerns are important modes of identifying children with speech and language delay. Despite the lack of evidence to support screening with brief formal instruments, it is the responsibility of primary care physicians to seek and address parents’ concerns and children’s obvious speech and language delays.
Nelson HD, Nygren P, Walker M, Panoscha R. Screening for speech and language delay in preschool children: evidence synthesis no. 41. Rockville, Md.: Agency for Healthcare Research and Quality, 2006. Accessed June 13, 2006, at: http://www.ahrq.gov/downloads/pub/prevent/pdfser/speechsyn.pdf.
Nelson HD, Nygren P, Walker M, Panoscha R. Screening for speech and language delay in preschool children: systematic evidence review for the U.S. Preventive Services Task Force. Pediatrics. 2006;117:e298–e319.
U. S. Preventive Services Task Force. Screening for speech and language delay in preschool children: recommendation statement. Pediatrics. 2006;117:497–501.
The series coordinator is Charles Carter, M.D., University of South Carolina Family Medicine Residency, Columbia, S.C.
The case study and answers to the following questions on screening for speech and language delay are based on the recommendations of the U.S. Preventive Services Task Force (USPSTF), an independent panel of experts in primary care and prevention that systematically reviews the evidence of effectiveness and develops recommendations for clinical preventative services. More detailed information on this subject is available in the USPSTF Recommendation Statement, the evidence synthesis, and the systematic evidence review on the USPSTF Web site (http://www.ahrq.gov/clinic/uspstfix.htm). The evidence synthesis and Recommendation Statement are available in print through the AHRQ Publications Clearinghouse (800–358–9295, e-mail, email@example.com).
This case study is part of AFP’s CME. See “Clinical Quiz” on page 1275.
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