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A federal task force recently examined how pediatricians diagnose and manage speech and language problems in young children. What does its new report say about screening for such developmental delays in primary care settings?
A federal task force is uncertain that pediatricians have a place in managing speech and language problems in children aged 5 years and younger, although research suggests that current efforts aren’t doing any harm, either.
Although there are tools and parameters that pediatricians can use to identify children who may be experiencing speech or language delays, a new report by the US Preventive Services Task Force (USPSTF) indicates that there is no evidence that screenings in the primary care setting do anything to improve the outcomes for those children.
Speech and language delays occur in roughly 6% of preschool-aged children. Although it may seem as though screening for such disorders prior to entry into elementary school programs would be helpful, the new research raises questions about the efficacy of primary care diagnoses and interventions.
“Learning to speak and use language correctly is a critical part of a young child’s development, and we care deeply about helping children and their families get the care and support they need,” says USPSTF Chair Albert L. Siu, MD, MSPH. “The Task Force looked at the current available evidence to determine whether using formal screening tools focused on speech and language issues would benefit all children under 5 who have not already been diagnosed with a communication, developmental, or hearing problem. We found that more research is needed at this time to reach a clear answer.”
According to the USPSTF findings, there is no evidence that current screening methods for speech and language disorders improve outcomes. The USPSTF review was conducted in an effort to update guidance on screening and treatment of speech and language disorders from 2006.
Several studies reviewed for the report evaluated the accuracy of traditional speech and language screening tools, and researchers found that sensitivity ranged from 50% to 94%. As for outcomes and treatments, although little evidence was found to show that typical interventions improved outcomes, they also produced no adverse effects.
Overall, the review determined that whereas some screening tools can accurately identify children in need of further diagnostic evaluation and intervention of speech and language disorders, there is little evidence to support a place for those tools in primary care settings such as pediatric practices.
“Ultimately, the evidence isn’t clear about whether screening with formal tools in primary care settings would help identify speech or language problems in children under age 5 who weren’t previously thought to have problems,” Siu says. “At this time, the Task Force concluded that the current evidence is insufficient to assess the balance of benefits and harms of the service and therefore could not make a recommendation for or against screening.”
According to the American Speech-Language-Hearing Association’s referral guidelines for pediatricians, there are a number of triggers that they suggest warrant further consideration, most often by way of a referral to a speech-language pathologist.
Some of those triggers include a 3-year-old child who is not understood by the family or caregivers; who can’t pronounce vowels; and who repeats himself or herself when he/she is not understood. At age 4 years, triggers for referral include not being understood by people whom the child does not know or caregivers; the inability to pronounce letters t, d, k, g, and f; and becoming sensitive when asked to repeat words said. By age 5 years, triggers include not being understood in all situations by most listeners; the inability to produce most speech sounds; and becoming frustrated when asked to repeat words said.
Some of these speech and language delays can be caused by cerebral palsy, craniofacial disorders such as a cleft palate, or a number of other articulation or phonological disorders.
The American Academy of Pediatrics (AAP) guidelines recommend that pediatricians perform surveillance for speech and language problems at every well-child visit using standardized developmental tools. The guidelines identify ages 9, 18, 24, and 30 months as appropriate screening ages despite the 2006 USPSTF conclusion that there was insufficient evidence to support the routine use of formal screening tools in primary care. The new review, commissioned in 2013, came to the same conclusion, but noted that the research reviewed for the report was lacking in many facets.
“We found no evidence to answer the overarching question of whether screening for speech and language delay or disorders improves speech and language outcomes,” according to the new USPSTF report. “As in the 2006 review, we found no studies that addressed the harms of screening for speech and language delays. Neither did we find any evidence about the role of enhanced surveillance by a primary care clinician once a child elicits clinical concern for speech and language delay.”
What else the research lacks is information on what specific factors associated with certain treatments are most effective, according to the Task Force. Siu says that in the absence of a clear recommendation, pediatricians should use their own clinical judgment in determining a child’s plan of care.
“In the absence of clear evidence on the harms and benefits of a preventive service, healthcare professionals should take into consideration current scientific research, expert opinion, their own depth of knowledge, and an understanding of the patient’s health history to make an informed decision about their patient’s care,” Siu advises. “If parents or clinicians raise concerns, then those children should be evaluated and, if needed, receive treatment. Pediatricians who have concerns about a child’s speech or language should ensure they are evaluated and treated, as appropriate.”
In a commentary published in Pediatrics following the release of the new USPSTF report. Robert G. Voigt, MD, and Pasquale J. Accardo, MD, point out that only 720 of the nation’s 10,000-plus board-certified pediatricians are certified in developmental-behavioral pediatrics, and only 255 are certified in neurodevelopmental disabilities. This makes attempts at referrals for children who fail screenings “futile,” because specialists are so few and far between. Instead, pediatricians must rely on their own limited training in this area, and use their clinical judgment in developmental evaluations.
Voigt and Accardo say that considering the importance of a child’s developmental status, the scarcity of subspecialists, and the prevalence of these types of developmental disorders, more emphasis needs to be placed on training pediatricians who are able to make clinical evaluations and diagnoses rather than provide simple screenings. Currently, the Accreditation Council of Graduate Medical Education program requirements for graduate medical education in pediatrics includes only a 4-week course in developmental-behavioral pediatrics.
“This represents a distressing mismatch between the amount of training received and future demands in daily pediatric practice,” according to Voigt and Accardo. “A substantial expansion of required subspecialty exposure to developmental evaluation and diagnosis during pediatric residency training should lead to increased confidence in using clinical judgment to address developmental concerns just like any other commonly presenting concern in daily pediatric practice. Such enhanced pediatrician competence in evaluation and diagnosis of the basic science of pediatrics might ultimately provide evidence for improved outcomes, which has so far been lacking in the USPSTF studies of screening.”
The USPSTF acknowledges there are shortcomings in the current research, and Liu agrees that more work is needed.
“Throughout its review of the current evidence, the Task Force identified that there are areas where more research is needed to help understand whether formal screening in primary care settings accurately identifies children needing interventions and whether identification ultimately results in important benefits,” Siu says. “These evidence gaps, among many other important research needs to improve the lives and health of children, are called out in the Task Force’s 4th annual Report to Congress.”