COMMENTARY

The Young Child With Speech Problems: Treat or Watch?

William T. Basco, Jr., MD, MS

Disclosures

September 29, 2017

The Resolution of Delayed or Disordered Speech in Children

Developmental speech disorders are reasonably prevalent, occurring in up to 5% of preschool children. Pediatric providers encounter them frequently. A child with "delayed" speech has typical speech and speech patterns, but these are delayed compared with 90% of his or her peers.[1] In contrast, "disordered" speech is marked by atypical errors seen in less than 10% of children at corresponding ages.

A study by Morgan and colleagues[1] examined persistence of speech difficulties in 4-year-old children to guide primary care practitioners in distinguishing children who warrant immediate evaluation from those who may be followed from a "watchful waiting" perspective. This longitudinal study enrolled infants in Melbourne, Australia, between 2003 and 2004. The initial cohort was assembled to represent children of different economic strata. At age 4 years, 1494 children had a speech and language evaluation. The study planned to reassess at age 7 years all children identified with speech errors at age 4 years (160, or 11% of the enrollees). Investigators were able to re-evaluate only 93 of these 160 children at age 7 years. Most were lost to follow-up, or their parents declined further evaluation. No clinical differences were found between the group who continued participation through age 7 years and those who did not.

The evaluations conducted at ages 4 and 7 years used standard and validated testing methods. Of the children retested at age 7 years, 60% had been diagnosed with a speech delay at age 4 years compared with approximately 40% who had been diagnosed with a speech disorder. Resolution was much more common among the children who had a speech delay (69.6%) compared with only 40.5% of the children who exhibited a speech disorder at age 4 years. In multivariable analyses, only the type of disorder (delay) present at age 4 years was associated with resolution of the speech error by age 7 years, and neither intelligence nor socioeconomic measures were associated with the results. The study authors concluded that delayed speech at age 4 years resolved in most children by age 7 years, suggesting that a watchful waiting approach would be appropriate for that group but not for those with disordered speech at age 4 years.

Viewpoint

A key take-home message of this study, from my standpoint, is the fact that even in the best-case scenario (delayed speech), 30% of children had a speech error that persisted to age 7 years, well into school age. So, we must remember that developmental speech disorders are problematic conditions that bear ongoing assessment and perhaps treatment. The accompanying online appendices demonstrate that seeking help from a speech language pathologist was not associated with resolution among the children who had a delay, but it was associated with resolution in the subset who had a speech disorder. With that in mind, they advocate prioritizing 4-year-olds with disordered speech for speech and language therapy in settings where help is not available to all children or wait lists are long. That certainly seems like a reasonable recommendation, but it is definitely worth noting that all of these children are at risk for persistence and need close follow-up. Furthermore, without data from a randomized controlled trial, it isn't possible to make this a strong recommendation.

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