Pediatricians Slam USPSTF's 2015 Update on Language Screening

Diana Swift

January 14, 2016

In its 2015 update statement on screening specifically for speech and language delay in asymptomatic preschool-age children, the US Preventive Services Task Force confirmed its 2006 report and concluded there is still insufficient ("I" rating) evidence to support a recommendation for or against language screening.

That conclusion has drawn fire from some practicing pediatricians, for whom screening is a cornerstone of good care. A letter published online January 4 in Pediatrics takes aim at the task force for failing to give due credence to proven positive outcomes in studies of early detection and intervention for a comprehensive array of developmental problems, language deficits included.

"General pediatricians like myself felt the [task force's] I evidence rating did not connect the dots between the proven benefits of periodic screening and the proven benefits of early intervention," Kevin Marks, MD, a primary care pediatrician in Eugene, Oregon, and coauthor of the letter with Frances Page Glascoe, PhD, a professor of pediatrics at Vanderbilt University in Nashville, Tennessee, told Medscape Medical News. "And it was befuddling why the [task force] chose to focus their review specifically on language and speech screening in the first place. Their review lacked applicability to the current standard of care."

Commenting to Medscape Medical News, Alex R. Kemper, MD, a task force member and a professor of pediatrics at Duke University Medical School in Durham, North Carolina, said, "The task force chose to evaluate speech and language delay and impairment because these problems are common in childhood." The update noted that speech and language delays/disorders have an estimated prevalence of 5% to 12% in children aged 2 to 5 years and can lead to a considerable burden of learning disability. Yet no specific recommendation exists regarding the regular implementation of formal language screening tools in the primary care setting.

In 23 reviewed studies, the task force found that sensitivity for detecting a true speech and language delay or disorder ranged from 50% to 94%, and specificity for detecting the absence of such delays ranged from 45% to 96%. And although 12 treatment studies improved outcomes in language, articulation, and stuttering, little evidence emerged for interventions improving other outcomes or for the potential harms of detection, such as the anxiety burden.

Dr Marks countered that the American Academy of Pediatrics recommends the use of broadband developmental, social-emotional, and autism-specific screening tools at regular intervals, and that language issues are part of this comprehensive approach.

He also found it bewildering that the task force's "systematic" review included a broadband developmental screen — the Ages and Stages Questionnaire — but excluded important randomized controlled trials such as that by Guevara and colleagues ( Pediatrics. 2013;131:30-37), which showed that developmental screening significantly increased earlier identification, timely referrals, and increased access to remedial services. "This excluded study is highly applicable to primary care," he said.

Moreover, the narrowness of the review's focus remains a concern, according to Dr Marks. "It's kind of like screening for iron deficiency with a complete blood count, but in your report you only look at the hematocrit," he said.

"Many experts in my field have had strong concerns about the way the [task force] did their literature review and about their final decision-making process," he added. For example, in a comment on the letter, Kenneth M. Carlson, MD, a pediatrician in Salem, Oregon, writes: "My 'key question' is, why exactly are expensive, outcome-focused studies needed about speech and language-specific screening in 'asymptomatic' (i.e., potentially undetected) children when that's not even what the [American Academy of Pediatrics] is recommending?"

Dr Carlson's comment also criticizes the task force for excluding the second most common broadband tool, the Parents' Evaluation of Developmental Status, in its analysis. Furthermore, he added, "Confusingly, when evaluating the accuracy of many different screens to identify speech-language delays, they grouped the [Ages and Stages Questionnaire] together with many other parent-report and practitioner-administered speech-language screening and assessment-level instruments."

Dr Kemper, however, defended the task force's overall methodology as an open process that conducts "a rigorous evaluation of existing scientific data regarding the effectiveness of screening and subsequent care."

Interpretation of an "I" Rating at Issue

Insurance implications are another issue raised by Dr Marks. Could the task force's statement potentially provide some carriers with a basis for denying reimbursement for current procedural terminology codes, such as 96110 for developmental testing? "I really hope that the statement doesn't cause problems with that," he said.

Such concerns, however, fall outside the task force's mandate, whose "role is limited to evaluating the science to determine the net benefit of a clinical preventive service," Dr Kemper said. "Our review of the scientific evidence may be only one of the inputs to determining insurance coverage; often it is the floor to determining minimal coverage, not the ceiling. Coverage decisions are the domain of payers, regulators, and legislators."

In a comment responding to the letter by Dr Marks and Dr Glascoe, task force chair Albert L. Siu, MD, MSPH, a professor of geriatrics and palliative care at Mount Sinai Health System in New York City, writes, "We would like to emphasize that the [task force] is not arguing against screening for speech delays or disorders. Instead, [it] identified a critical gap in the evidence needed to demonstrate that routinely screening all children for language delays and disorders in primary care might improve language outcomes."

Dr Siu also stresses that, " 'I statements' are not recommendations against screening but calls for more research and better evidence" that "will ultimately lead to the information needed to provide the best care for children and their families."

According to Joseph F. Hagan Jr, MD, a clinical professor in pediatrics at the University of Vermont College of Medicine and the Vermont Children's Hospital in Burlington, and coeditor of the Bright Futures Guidelines, the screening report "is not such a huge controversy." In his view, the protests stem from a lack of understanding he has noted among fellow pediatricians that an inconclusive I rating will not change clinical practice. "It's not a D rating that says 'Don't do it.' It really just supports the status quo," he commented to Medscape Medical News.

Dr Hagan applauded the task force for tackling the underserviced area of preventive health recommendations for children and said its call for further research might open the door to more funding for future studies. But among pediatricians, who are "the champions of developmental screening," any perceived criticism of screening "is like criticizing motherhood, apple pie, and breast-feeding," he said. What the report is really telling pediatricians, he added, is "beat your breast a little less early and be careful of your clients."

Although acknowledging that many pediatricians are "trained that screening for speech and language delay and disorder is an important component of preventive care," Dr Kemper said, "we hope that child healthcare providers partner with researchers to better understand the screening process and how to improve outcomes." At present, however, it is not clear whether language screening actually leads to improved outcomes.

To Dr Hagan's mind, the task force's narrow focus on language development may have been somewhat of a practical decision in light of the challenge of reviewing the literature across all developmental areas. "I suspect they may have wanted to break it down into bites, and this was the first bite," he said. "The good news is that they're studying developmental screening in kids. The bad news is that because there's so much that's not been adequately studied, they're saying it needs more study."

Dr Glascoe is the author of and receives royalties for the Parents' Evaluation of Developmental Status, Developmental Milestones, and Brigance Screens. Dr Marks, Dr Carlson, Dr Siu, and Dr Hagan have disclosed no relevant financial relationships.

Pediatrics. Published online January 4, 2016. Letter abstract, Carlson comment, Siu comment

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