Early identification of language delays--are we there yet?

Speech and language impairments result in significant childhood morbidity. In the 2001–2002 school year, more than one million students served in the US public schools’ special education programs were categorized as having a speech or language impairment, while almost 17% of children ages 3–21 years served in federally funded programs for the disabled carried the same categorization. Early identification of, and intervention for, children with language delays appear to offer the best hope for improved outcomes, and are important goals of early childhood services. Unfortunately, many children with special needs, including language delay—up to 70% in one series—are not identified prior to school entry. This lost opportunity for intervention at a critical period in the child’s life course might lead to long-term adverse consequences and to later need for potentially costly special education services. Prevention of language problems would yield even greater benefits. Consequently, there is considerable interest in finding effective ways both to prevent and identify language delays in the preschool years. In this issue of the Journal, King et al report the findings of a study in Hawaii on a group of three year olds identified at birth as having socio-environmental risks for language delay. Study participants were randomized at birth to intervention and control groups. The intervention consisted of home visiting by trained paraprofessionals from Hawaii’s Healthy Start Program (HHSP) who educated parents about child development, modeled effective parent-child interactions, and linked families to a medical home. The home visitors also performed developmental surveillance, using the Infant and Child Monitoring Questionnaire (ICMQ), an early version of the current Ages and Stages Questionnaire (ASQ). Language was assessed at age three years using the Preschool Language Scale, Third Edition (PLS-3). King et al found, not unexpectedly, that the estimated prevalence of language delays in this group of at-risk children was much higher than expected from a national standardization sample, with 10% children classed as having ‘‘severe delays’’ (>2 SD below the mean) and 49% children having any degree of language delay (>1 SD below the mean). Exposure to multiple languages at home did not appear to account for this high prevalence, and while addition of other language measures might have yielded a more detailed picture of language ability, it is unlikely that this would have materially altered the findings. Prevalence of early language delays in other reported series vary widely from 2–19%, depending on definitions, populations studied and cut-off points. Disappointingly, in this series, no difference in prevalence rates was found between intervention and control groups. Even more concerning, rates of identification did not differ between the groups, and children with severe delays in the home visiting group actually showed a trend towards being less likely to be identified by their parents as delayed compared with children with severe delays in the control group. Another important finding of the study, and one which has major implications for service provision, is that of those children who were identified by a home visitor— either correctly or incorrectly—as having a language delay, only two of 72 were referred back to their primary care providers, and none were referred to early intervention programs. Potential reasons for the lack of demonstrated effectiveness of the home visiting program bear some reflection. First, the training for the home visitors was brief–only 4–6 hours in general child development and an additional 6–8 hours on language development. Second, almost half of the families in the intervention group were no longer considered ‘‘active’’ in the program by the time the child reached the age of 12 months, possibly indicating some lack of acceptance of, or engagement with the program by the community. Third, even when home visitors identified language delay, they lacked training in how to raise this issue with parents, especially when the parents themselves were not expressing any concerns. The authors suggest that an over-emphasis on parent empowerment may have prevented home visitors from voicing concerns and motivating parents to action about child development. Fourth, although the home visitors were trained in administration of the ICMQ, it is unclear whether they were sufficiently trained in how to access early childhood developmental service systems and coached in how to effectively connect the surveillance activity with a responsive service delivery pathway. Lack of knowledge of services available for children with language delay, referral routes, eligibility criteria and potential benefits of, or need for intervention may all have contributed to an inability to successfully refer children to appropriate interventions. Lack of communication between the home visitors and Commentary