Risk and Protective Factors Associated

With Speech and Language Impairment

in a Nationally Representative Sample
of 4- to 5-Year-Old Children

Linda J. Harrison
Sharynne McLeod
Purpose: To determine risk and protective factors for speech and language
Charles Sturt University, Bathurst, Australia
impairment in early childhood.
Method: Data are presented for a nationally representative sample of 4,983 children
participating in the Longitudinal Study of Australian Children (described in McLeod
& Harrison, 2009). Thirty-one child, parent, family, and community factors
previously reported as being predictors of speech and language impairment were
tested as predictors of (a) parent-rated expressive speech/language concern and
(b) receptive language concern, (c) use of speech-language pathology services, and
(d) low receptive vocabulary.
Results: Bivariate logistic regression analyses confirmed 29 of the identified factors.
However, when tested concurrently with other predictors in multivariate analyses,
only 19 remained significant: 9 for 2–4 outcomes and 10 for 1 outcome. Consistent
risk factors were being male, having ongoing hearing problems, and having a
more reactive temperament. Protective factors were having a more persistent and
sociable temperament and higher levels of maternal well-being. Results differed
by outcome for having an older sibling, parents speaking a language other than
English, and parental support for children’s learning at home.
Conclusion: Identification of children requiring speech and language assessment
requires consideration of the context of family life as well as biological and
psychosocial factors intrinsic to the child.
KEY WORDS: risk factor, protective factor, epidemiology, speech, language,
communication

S
peech and language acquisition in early childhood is a powerful
indicator of the developmental and cognitive abilities that under-
pin children’s successful transition to school (Nelson, Nygren, Walker,
& Panoscha, 2006). Longitudinal results from the U.S. National Institute
of Child Health and Human Development [NICHD] Study of Early Child
Care and Youth Development have demonstrated that “multiple path-
ways all funnel through one final common pathway, namely the child’s
language skills, just before entering school I to define the child’s ‘read-
iness’ for school” (NICHD, 2004, p. 28). These findings, particularly when
viewed in combination with prevalence studies (e.g., King et al., 2005;
Law, Boyle, Harris, Harkness, & Nye, 2000; McLeod & Harrison, 2009;
McLeod & McKinnon, 2007) showing that a significant proportion of chil-
dren do not successfully acquire speech and language prior to school, are
compelling. They point to the need to identify and provide support for

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children at risk of speech and language impairment
in their early childhood years, which is when they are
most likely to benefit from early intervention (Almost &
Rosenbaum, 1998; Gibbard, Coglan, & MacDonald, 2004).
Early detection and early intervention can reduce the
severity and longevity of speech and language difficul-
ties (Gibbard et al., 2004; Schwarz & Nippold, 2002);
however, many children who are eventually identified
as having speech and language impairment display no
organic basis and few obvious indicators in the first years
of life (Dollaghan & Campbell, 2009; Roulstone, Miller,
Wren, & Peters, 2009). Consequently, not all children who
may benefit from and be eligible for speech-language
pathology services are identified or referred prior to com-
mencing school.
Primary care professionals, such as doctors, nurses,
and early childhood teachers, are often expected to iden-
tify children who may be at risk and may require a speech
and language assessment to diagnose a speech and
language impairment. The methods that primary care
professionals use to diagnose impairment tend to be
(a) comparison with other children of a similar age,
(b) acknowledgment of parental concern, and (c) comple-
tion of checklists of speech and language milestones such
as having fewer than 50 words or not combining words
at 24 months (e.g., Coplan, Gleason, Ryan, Bourke, &
Williams, 1982; Luinge, Post, Wit, & Goorhuis-Brouwer,
2006). Recognition and identification of known risk and
protective factors is another method that can be employed,
particularly when the above three screening methods are
either unavailable, inappropriate for a particular context,
or lack sensitivity. Tomblin, Hardy, and Hein (1991) have
recommended that “programs of preschool identification
should consider the inclusion of a registry of children who
are at risk for a communication disorder” (p. 1096). How-
ever, as Nelson et al. (2006) concluded, “A list of spe-
cific risk factors to guide primary care physicians in
selective screening has not been developed or tested”
(p. e302).
Current bioecological theories (Bronfenbrenner, 2005)
provide a useful framework for addressing risk and pro-
tective factors for children’s health and development.
Bioecological models elucidate the interacting influ-
ences of proximal social and psychological contexts (e.g.,
parental and family characteristics) and distal social con-
texts (e.g., community characteristics and supports) with
the inherited and biological characteristics of the indi-
vidual. This approach accords with the International
Classification of Functioning, Disability, and Health (World
Health Organization, 2007), which recognizes the com-
plex interrelationships that exist between biological, indi-
vidual, and societal factors that influence child functioning.
Research investigations of the predictors of speech and
language impairment that are consistent with these bio-
ecological models seek to include a wide range of variables
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describing parental, family, and neighborhood attributes,
along with documentation of child health and psycho-
social characteristics (e.g., Reilly et al., 2007; Zubrick,
Taylor, Rice, & Slegers, 2007). Such studies are able
to examine concurrently a large number of possible pre-
dictors of speech and language delay or impairment and
use complex statistical analyses to identify the best set
of predictors. Multivariable designs of this type, how-
ever, are relatively rare in studies of speech and language
impairment. A systematic review of risk and protective
factors associated with screening for speech and language
impairment in early childhood undertaken by the U.S.
Preventative Services Task Force (Nelson et al., 2006;
U.S. Preventative Services Task Force, 2006) showed
that no studies encompassed all the potential predictor
domains (such as family history, child gender, socioeco-
nomic status (SES), birth order, perinatal factors, paren-
tal education, medical conditions, and other). Most of the
16 studies reviewed had addressed only one or two of
these domains. Nelson et al. (2006) concluded “The most
consistently reported risk factors include a family history
of speech and language delay, male gender, and perina-
tal factors; however, their role in screening is unclear”
(p. e302).
For the present study, articles included in the U.S.
Preventative Services Task Force study (2006) have been
reviewed again, along with additional literature, to sum-
marize evidence that confirms or disconfirms an associa-
tion between each risk factor and childhood speech and
language impairment. Risk/protective factors are re-
viewed within the domains identified by Nelson et al.
(2006) plus additional domains: child hearing status, oral
sucking habits, temperament, parent language spoken at
home, minority status/race, maternal mental health and
maternal age, family support for learning, family smok-
ing habits, and neighborhood disadvantage (see Table 1).
These domains are grouped within three broad categories:
child, parent, and family/community. A brief summary of
the literature for each domain is presented, followed by
consideration of design issues that may influence or ex-
plain any differences in the reported findings.
Child Factors
Sex. Sex of child was examined in 14 studies, as
shown in Table 1. A significant association between be-
ing male and having an increased risk for speech and/or
language impairment was found in 11 of these studies
(Campbell et al., 2003; Chevrie-Muller, Watier, Arabia,
Arabia, & Dellatolas, 2005; Choudhury & Benasich, 2003;
Prior et al., 2008; Reilly et al., 2006, 2007; Stanton-
Chapman, Chapman, Bainbridge, & Scott, 2002; Tomblin
et al., 1991; Yliherva, Olsen, Maki-Torkko, Koiranen, &
Jarvelin, 2001; Yoshinaga-Itano, Sedey, Coulter, & Mehl,
1998; Zubrick et al., 2007).
Harrison & McLeod: Risk and Protective Factors 509
 Perinatal factors. Perinatal factors were examined
in 11 studies, and a significant association with speech
and language impairment was found in 5. Prenatal fac-
tors were associated with risk for speech and language
impairment in Fox, Dodd, and Howard (2002), who iden-
tified significant effects for extreme stress, maternal in-
fections, and medications that could cause damage to the
fetus during pregnancy, and in a population-based inves-
tigation of birth risk factors for specific language impair-
ment (SLI) by Stanton-Chapman et al. (2002), who noted
that late or no prenatal care was a significant predictor
of SLI 6 years later, at school.
Less consistent results have been reported for peri-
natal difficulties. For example, Fox et al. (2002) found
that “forceps or ventouse delivery, induced delivery, com-
plications such as umbilical cord prolapse, infections,
preterm birth, and post-partum resuscitation” (p. 122)
were significant predictors of speech impairment. Stud-
ies by Weindrich, Jennen-Steinmetz, Laucht, Esser, and
Schmidt (2000) and Yliherva et al. (2001) have also linked
perinatal factors to speech and language problems. In
contrast, Peters, Grievink, van Bon, van den Bercken,
and Schilder (1997); Reilly et al. (2006, 2007); Tomblin
et al. (1991); and Tomblin, Smith, and Zhang (1997) found
that postnatal factors did not present significant risks
for speech and language impairment. For example, Tomblin
et al. (1991) found that birth events such as “infections,
low birth weight, breathing difficulty, ototoxic drugs, feed-
ing problems, transfusions, and birth defects” (p. 1101)
did not predict poor communication status. Tomblin et al.
(1997) also found that birth events including type of
delivery, induction of labor, duration of labor, and labor
and birth complications were not significant risk factors.
Existing findings are also inconsistent for prema-
turity and low birth weight. Reilly et al. (2006, 2007)
found that being born preterm (< 36 weeks) was not a
significant risk factor for early language delay. Simi-
larly, Tomblin et al. (1997), who used < 2,500 g as the cut-
off, and Reilly et al. (2007), who used a continuous scale of
birth weight in kilograms, have reported that low birth
weight was not a significant predictor. In contrast, Zubrick
et al. (2007) found that low birth weight and premature
birth were independently significant for late language
emergence. Similar results were noted by Stanton-
Chapman et al. (2002): low birth weight (< 2,500 g), very
low birth weight (< 1,500 g), and a low 5-min Apgar score
were significant risk factors for school-age specific lan-
guage impairment.
Multiple birth. Two studies based on the same co-
hort have examined the association between multiple
birth and the risk for language impairment. Reilly et al.
(2006) found twin birth to be a significant risk factor for
communication impairment in 8- and 12-month-old in-
fants; however, by the time this cohort reached 2 years of
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age, twin status was not a significant risk factor (Reilly
et al., 2007).
Medical conditions. Mixed findings have been re-
ported for the impact of child illness and infection on
speech and language impairment. Medical conditions
were examined in seven studies and a significant associ-
ation was found in five. Singer et al. (2001) found that
patent ductus arteriosus and bronchopulmonary dyspla-
sia were significant risk factors associated with speech
and language impairment. Choudhury and Benasich (2003)
reported that autoimmune diseases presented a signif-
icant risk, but asthma did not. The U.S. Preventative
Services Task Force review (2006) excluded studies of
otitis media (OME) as a risk factor because it is “a com-
plex and controversial area” (Nelson et al., 2006, p. e302).
Two studies have reported a significant association be-
tween OME and speech impairment in bivariate anal-
yses but a nonsignificant association when multivariate
analyses were applied (Campbell et al., 2003; Fox et al.,
2002). Peters et al. (1997) indicated that “OME even when
combined with a number of other risk factors produces
only minor effects on later language” (p. 31). In contrast,
Shriberg, Friel-Patti, Flipsen Jnr, and Brown (2000),
using structural equation modeling, reported a signif-
icant relationship between otitis media and speech /
language outcomes.
Hearing status. Impaired hearing was found to be a
significant risk factor for difficulties with speech, lan-
guage, and learning in a large study of 8,370 Finnish
children (Yliherva et al., 2001) but not a significant risk
factor in the study by Singer et al. (2001) of over 200 chil-
dren. In a study of 150 children with hearing impairment,
Yoshinaga-Itano et al. (1998) reported that children had
greater difficulties with speech and language develop-
ment if they were identified with a hearing impairment
after the age of 6 months; identification prior to 6 months
coupled with subsequent early intervention was associ-
ated with increased language scores.
Oral sucking habits. Oral sucking habits, including
breast-feeding, have been found to be both a risk and a
protective factor in studies that have examined this
factor. Fox et al. (2002) found that excessive sucking of
pacifiers, or thumb or bottle usage as a pacifier, was a
moderate predictor of speech impairment. On the other
hand, Tomblin et al. (1997) demonstrated that breast-
feeding for less than 9 months was associated with an
increased risk of speech and language impairment.
Temperament. Three studies have examined child
temperament characteristics as possible risk or protec-
tive factors for speech and language impairment. Hauner,
Shriberg, Kwiatkowski, and Allen (2005) considered the
effect of different aspects of child temperament as risk
factors for “increased severity of expression of speech
delay” (p. 635). Increased severity was related to negative
 Table 1. Summary of significant and nonsignificant risk factors for speech and language impairment for children based on the systematic review by the U.S. Preventative Task Force (2006) and additional studies.

Demographic information Child variables Parent variables Family and community variables

Oral Minority Parental Maternal Family Home Smoking

Study and Age in Outcome Male Perinatal Multiple Medical Hearing sucking Temper- Family Languages status Mother’s Father’s mental age at size and learning in the Socioeconomic Neighborhood
country Number months measure sex factors birth condition status habits ament history spoken or race education education health birth birth order activities household status disadvantage

Brookhouser 24 cases 28–62 Language – – – y – – – n – – – – – – – – – – –

et al. (1979)
USA
Campbell et al. 398 cases and 36 Speech y – – n – – – y – n y – – – – – – n –
(2003) USA 241 controls
Chevrie–Muller 2059 in cohort 42 Language y – – – – – – – y – y y – – – – – – –
et al. (2005)*
France
Choudhury & 42 cases and 36 Language y n – y/n – – – y – – n n – y/n y – – n –
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Benasich 92 controls
(2003) USA
Felsenfeld & 156 adopted 84 Speech n – – – – – – y – – – – – – – n – – –
Plomin (1997)* and
USA nonadopted
children
Fox et al. (2002) 65 cases and 32–86 Speech n y – n – y – y – – – – – – – – – – –
Germany 48 controls
Hauner et al. 29 cases and 36–72 Speech – – – – – – y – – – – – – – – – – – –
(2005)* USA 87 controls
Lyytinen et al. 107 with risk of 0–54 Speech and – – – – – – – y – – – – – – – – – – –
(2001) Finland dyslexia and language
93 without
Peters et al. (1997) 946 in cohort 84–96 Language n n – y – – – – y – y y – – – – – – –
Netherlands
Prior et al. (2008)* 1,911 in cohort 12 and 24 Language y – – – – – y – – – – – y – – – – – –
Australia
Reilly et al. (2006)* 1,911 in cohort 8 and 12 Language y n y – – – – y – – – – n – – – – – y
Australia
Harrison & McLeod: Risk and Protective Factors

Reilly et al. (2007)* 1,720 in cohort 24 Language y/n n n – – – – y y/n – y/n – n y/n n – – – n
Australia
Singer et al. (2001) 98 cases and 36 Language – – – y n – – – – y n – – – – – – y
USA 70+95
controls
Stanton-Chapman 5,862 cases 72–84 Language y y – – – – – – n – y – – n y – n – –
et al. (2002) and
USA 201,834
not
identified
Tallal et al. (1989) 76 cases and 48–59 Language – – – – – – – y – – y y – – – – – – –
USA 54 controls
Tomblin et al. 662 in cohort 30–60 Speech and y/n n – – – – – y – – n y – – y – – – –
(1991) USA language
Tomblin et al. 177 cases and kindergarten Speech and – n – – – y – y/n – – y y – y – – y – –
(1997) USA 925 controls language

(Continued on the following page)

511
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Table 1 Continued. Summary of significant and nonsignificant risk factors for speech and language impairment for children based on the systematic review by the U.S. Preventative Task Force (2006) and additional studies.

Demographic information Child variables Parent variables Family and community variables

Oral Minority Parental Maternal Family Home Smoking

Study and Age in Outcome Male Perinatal Multiple Medical Hearing sucking Temper- Family Languages status Mother’s Father’s mental age at size and learning in the Socioeconomic Neighborhood
country Number months measure sex factors birth condition status habits ament history spoken or race education education health birth birth order activities household status disadvantage

Weindrich et al. 320 in cohort 54 and 96 Speech and – y – – – – – – – – y y y – – – – – –

(2000) language
Germany
Whitehurst et al. 62 cases and 24–38 Language – – – – – – – n – – – – – – – – – – –
(1991) 55 controls
Yliherva et al. 8,370 in cohort 96 Speech and y y – y/n y – – – – – y – – y y – – – –
(2001) Finland language
Yoshinaga–Itano 150 cases 13–36 Speech and y – – – y – – – – n n – – – – – – n –
et al. (1998) USA language
Zubrick et al. 1,766 in cohort 24 Language y y – – – – n y – y/n n n n n y – n n n
(2007)*
Australia

Note. y = yes, the variable was examined and there was a statistically significant association; n = no, the variable was examined and was not associated with speech and/or language delay; y/n = different findings for different outcomes; – = the variable was not examined.
Asterisk indicates studies that were not included in the review by the U.S. Preventative Services Task Force (2006).
affect associated with low approachability/sociability,
negative mood, and low task persistence. Prior et al.
(2008) found that having a shy temperament was nega-
tively related to vocabulary production and communi-
cation and symbolic development in a large cohort of 1- to
2-year-old children. On the other hand, in Zubrick et al.
(2007), only one of nine dimensions of child temperament
(negative mood) occurred more frequently in 2-year-old
children with late language emergence.
Parent Factors
Family history of speech and language problems.
Thirteen studies recorded family history of speech, lan-
guage, and/or learning difficulties, with 11 identifying
this as a risk factor for childhood speech and language im-
pairment (Campbell et al., 2003; Choudhury & Benasich,
2003; Felsenfeld & Plomin, 1997; Fox et al., 2002;
Lyytinen et al., 2001; Reilly et al., 2006, 2007; Tallal,
Ross, & Curtiss, 1989; Tomblin et al., 1991, 1997; Zubrick
et al., 2007). Of these, Tomblin et al. (1997) found that
paternal family history was significant, but maternal
history was not. Three other studies have reported that
family history of speech / language impairment (Brookhouser,
Hixson, & Matkin, 1979; Whitehurst et al., 1991) and
family history of hearing loss (Tomblin et al., 1991) were
not significantly associated with language impairment
or poor communication status in children. The impact of
family history may be due to genetic or environmental
influences or to a combination of both. This question has
been examined by Felsenfeld and Plomin (1997) in a study
of adopted and nonadopted children. Family history for
biological parents was a significant risk factor for speech
impairment, whereas for adoptive parents it was not.
Their results support the view that the biological basis of
family history has a stronger influence on children’s speech
and language than the home learning environment.
Languages spoken. Risk for speech and language
impairment in children with a nondominant language
background has been demonstrated in the case of non-
English speakers in an English-dominant society (Reilly
et al., 2007), non-French speakers in a French-dominant
society (Chevrie-Muller et al., 2005), and non-Dutch speak-
ers in a Dutch-dominant society (Peters et al., 1997). In
contrast, Stanton-Chapman et al. (2002), who studied
an English-dominant U.S. state with a large Spanish-
speaking population, reported that Spanish and other
non-English speakers were “less likely to be placed in SLI
classrooms than native-English speakers” (p. 397).
Minority status or race. Risk for speech and lan-
guage impairment has been studied in relation to minority
status or race. Singer et al. (2001) reported that children
of a minority race were at greater risk than their peers;
however, Campbell et al. (2003) found that identification
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as African-American was not a significant risk factor.
Minority status was not a significant factor in the study
conducted by Yoshinaga-Itano et al. (1998).
Educational level of mother and father. Of 14 studies
that have examined the association between parents’
educational level on children’s speech and language ac-
quisition, 10 reported a risk for speech and language
impairment at low parental educational level. These
included studies of only mother’s education (Campbell
et al., 2003; Peters et al., 1997; Reilly et al., 2007; Stanton-
Chapman et al., 2002; Yliherva et al., 2001), only father’s
education (Tomblin et al., 1991), and both mother’s and
father’s education (Chevrie-Muller et al., 2005; Tallal
et al., 1989; Tomblin et al., 1997; Weindrich et al., 2000).
In contrast, 4 studies have shown that parental educa-
tion level was not a significant risk factor (Choudhury
& Benaisch, 2003; Singer et al., 2001; Yoshinaga-Itano
et al., 1998; Zubrick et al., 2007).
Parental mental health. Five studies that have ex-
amined this domain reported mixed results. Three stud-
ies found that indicators of parental mental health were
not associated with speech and language impairment in
8- to 12-month-old infants (Reilly et al., 2006) or 2-year-
olds (Reilly et al., 2007; Zubrick et al., 2007). In contrast,
Prior et al. (2008) reported that maternal psychosocial
indices, specifically mothers’ rate of coping and partner
relationship satisfaction, were positively associated with
language development at 24 months, and Weindrich et al.
(2000) found that parental mental health was a risk fac-
tor for speech, language, reading, and spelling in children
aged 54 and 96 months.
Maternal age at birth of child. Studies that exam-
ined maternal age at the birth of the child have reported
mixed findings for speech and/or language impairment.
Younger mothers have been identified in risk groups
for children with specific language impairment (Tomblin
et al., 1997) and poor speech and language abilities
(Yliherva et al., 2001). Choudhury and Benasich (2003)
noted that younger maternal age was a characteristic of
families with a history of speech language impairment
but was not linked to children’s assessed receptive and
expressive language at age 3 years. Similarly, Stanton-
Chapman et al. (2002) reported no relationship between
maternal age and school-identified specific language im-
pairment, after accounting for the effects of other bio-
logical and environmental risks. Reilly et al. (2007) found
that older maternal age was a significant risk factor for
communication and symbolic behavior at age 24 months
but not for vocabulary production.
Family and Community Factors
Family size. Findings linking speech and language
acquisition with the number of siblings, the number of
Harrison & McLeod: Risk and Protective Factors 513
children in the household, and birth order have been
largely consistent. Choudhury and Benasich (2003) dem-
onstrated that an increased number of children in the
household was a significant risk factor for language
impairment. Yliherva et al. (2001) found that having
more than four children in the household increased risk
of speech, language, and learning difficulties. Tomblin
et al. (1991) demonstrated that children who held later
birth positions in the family were more likely to have
a poor communication status between 2.5 and 5 years
of age, and, similarly, Stanton-Chapman et al. (2002)
reported that children whose birth position was third
or higher were more likely to be identified as having
specific language impairment at age 6–7 years. Zubrick
et al. (2007) reported that the presence of two or more
siblings was a risk for language delay in a sample of
2-year-olds, and Reilly et al. (2007), who studied the
same age group, reported that birth order was a risk for
vocabulary production but not for communication and
symbolic behavior.
Home learning activities. In a study of adopted
and nonadopted children, Felsenfeld and Plomin (1997)
used the HOME Scale of family environment (Caldwell
& Bradley, 1984) and found that family environment
was not significantly associated with speech outcome at
age 7.
Smoking in the household. Tomblin et al. (1997)
found that maternal smoking in the household increased
the risk of speech and language difficulties but that this
was mediated by maternal education levels. Zubrick et al.
(2007), on the other hand, reported no effect of maternal
smoking (current and during/before pregnancy) on late
language emergence, and Stanton-Chapman et al. (2002)
found no effect of smoking during pregnancy on school-
identified specific language impairment.
Socioeconomic factors. Of the five studies that con-
sidered family SES (i.e., combined yearly income, occu-
pational prestige, education levels, and qualification for
Medicaid health insurance), only one found a significant
risk for language impairment (Singer et al., 2001). Low
SES was not identified as a risk factor by Campbell et al.
(2003), Choudhury and Benasich (2003), Yoshinaga-Itano
et al. (1998), or Zubrick et al. (2007).
Neighborhood disadvantage. Two studies included
information provided by the census-based Socio-Economic
Indexes for Areas (SEIFA) from the Australian Bureau
of Statistics (ABS, 2003) as a measure of neighborhood
disadvantage. Reilly et al. (2006, 2007) reported that
lower scores on the Index of Disadvantage (i.e., living in
a more disadvantaged area) was a significant predictor
for language difficulties at age 8–12 months but not at
age 24 months. Zubrick et al. (2007) noted no difference
for children with and without late language emergence
by SEIFA scores.
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Methodological Considerations
When Examining Studies
to Determine Risk Factors
As can be seen from the collation of findings set out
in Table 1, varying results have been reported as to
whether or not each of the factors reviewed presents as a
significant risk for childhood speech and language im-
pairment. These differences make it difficult to provide
a definitive list of specific risk factors to guide primary
care professionals (cf. Nelson et al., 2006). There are
three main reasons for the observed differences in study
results: (a) differences in the size and nature of the sam-
ples, (b) differences in the speech and language outcome
measures that have been used to identify impairment,
and (c) differences in the range and number of possible
predictor variables included in the design and the anal-
yses that have been applied to these variables.
Size and nature of the sample. The reviewed studies
have used two sampling techniques: clinical sampling
with or without a control group and cohort studies that
identify children with and without speech and language
impairment within the full population. Studies utilizing
the former approach tend to have relatively small sam-
ples (e.g., 24 children aged 28–62 months in Brookhouser
et al., 1979; 63 cases and 48 controls in Fox et al., 2002)
with some exceptions (e.g., 177 cases and 923 controls in
Tomblin et al., 1997), whereas the latter includes larger
samples (e.g., 8,370 Finnish children recruited by Yliherva
et al., 2001; 1,911 Australian children reported on by Prior
et al., 2008, and Reilly et al., 2006; 207,693 children in the
Florida cohort surveyed by Stanton-Chapman et al.,
2002). Larger population-based samples have greater var-
iability across predictors, which may mask or blur differ-
ences observed in clinical-control samples.
The samples also differ by the target age and the age
range of the study children. In some studies, children were
examined at a specific age (e.g., 36 months in Campbell
et al., 2003; 96 months in Yliherva et al., 2001), whereas
other studies examined children over a wide age range
(e.g., 30–60 months in Tomblin et al., 1991; birth to
54 months in Lyytinen et al., 2001). Sampling differences,
both in terms of the heterogeneity of the samples (cf.
Nelson et al., 2006) and the likelihood of sampling con-
founds (Zubrick et al., 2007), have constrained the eval-
uation of risk factors for speech and language impairment
in early childhood. Furthermore, it is likely that “predic-
tive relationships change over time” (Zubrick et al., 2007,
p. 1588) such that certain risk factors become more
salient at younger or older ages (see Reilly et al., 2006,
vs. Reilly et al., 2007; see Table 1).
Identification of speech and language impairment.
Differences in results also reflect the type and specificity
of the speech and language measures used to identify
the target group. The majority of the reviewed studies
considered both speech and language outcomes, but
some considered speech outcomes only whereas others
considered language outcomes only. Reilly et al. (2006,
2007) found that different outcome measures identified
different risk and protective factors. The source of diag-
nosis also varies, being based on parent or teacher report
or on direct assessment of speech and language skills. Al-
though there is evidence of correspondence across these
sources (see McLeod & Harrison, 2009, for a discussion),
there has not, as yet, been a systematic comparison of
risk factors in relation to parent, teacher, and direct as-
sessment sources of identification.
Range, number, and analysis of possible predictor
variables. Table 1 illustrates the range, number, and
type of predictors that were included and analyzed as
risk or protective factors in the reviewed studies. Some
studies focused on the predictive strength of a small
number of domains (e.g., two in Brookhouser et al., 1979,
and Whitehurst et al., 1991); others have a broader cov-
erage (e.g., five to seven domains in Campbell et al.,
2003; Tomblin et al., 1991, 1997); and some have included
most of the identified domains (e.g., 10 in Reilly et al.,
2007; 12 in Zubrick et al., 2007). The inclusion of mea-
sures from a large number of domains enables the use of
multivariate analysis techniques, which have been shown
to negate previous findings using bivariate analyses. For
example, using multivariate analyses, Reilly et al. (2007)
and Zubrick et al. (2007) examined a large number of
known risk factors for language delay in two samples
of Australian 2-year-olds. In both studies, results con-
firmed only three or four predictors: male sex, perinatal
factors, family history, and presence of siblings in the
Zubrick et al. study; and family history, low maternal
education, and non-English-speaking background in the
Reilly et al. study. Note, however, that a large sample
size is required when seeking to test predictors from
multiple domains. The discrepancies between the small
number of significant predictors identified in multivar-
iate analyses versus the more diverse range of predictors
identified in bivariate analyses warrant further inves-
tigation. Such work is needed to investigate possible con-
founding relationships between child biological factors
and parental or family factors.
Aim of the Present Study
Several groups of researchers (Campbell et al., 2003;
Nelson et al., 2006; Reilly et al., 2006, 2007; Tomblin
et al., 1991; Zubrick et al., 2007) have sought to identify a
set of predictors that would provide a means of identi-
fying children for speech and language assessment, us-
ing different analytical techniques and with differing
levels of success. The present study sought to extend this
work by assessing the unique and collective effects of a
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comprehensive range of previously identified risk and
protective factors for speech /language acquisition. It
also sought to address some of the weaknesses of pre-
vious research by focusing on a large population-based
sample of children of a similar age who were approach-
ing the beginning of formal schooling and by including
a range of sources and types of information to identify
speech/language impairment status. This article reports
on the second of two studies examining speech and lan-
guage impairment in a nationally representative popula-
tion sample of Australian children. The first study (McLeod
& Harrison, 2009) determined the prevalence of ex-
pressive and receptive speech and language impairment
based on four measures: two reported by parents, one
directly assessed by trained interviewers, and period
prevalence of attendance at speech-language pathology
services as reported by parents and teachers. Building
on these findings, the present study used the same four
measures of speech and language impairment as bi-
nomial outcomes to test the effects of a wide range of
previously identified risk/protective factors. Bivariate
effects for each of these factors were tested, followed by
multivariate analyses to identify the best set of predic-
tors from a range of child, parent, family, and community
factors.
Method
The Study
As with the companion article (McLeod & Harrison,
2009), the current study examined data collected from
the kindergarten cohort of children in the first wave (age
4–5 years) of Growing Up in Australia—The Longitudi-
nal Study of Australian Children (LSAC; Sanson et al.,
2002). LSAC is the first comprehensive national study of
Australian children, funded by the Australian Govern-
ment to examine children’s health and development over
time and within the social, economic, and cultural envi-
ronments of the families and communities in which they
are growing up. Recruitment of the sample using the
most comprehensive database of Australia’s population
was facilitated by the Australian Government and the
Health Insurance Commission. An overview of LSAC and
additional details about sample recruitment and data
weighting are provided in McLeod and Harrison (2009).
LSAC data were weighted to allow for unequal probabil-
ities of inclusion in the study and to ensure that the LSAC
sample matched families in the Australian population
with a 4- to 5-year-old child on a wide range of parental
and family characteristics, including parents’ ethnicity,
country of birth, education, and income; family size and
structure; and whether the mother spoke a language other
than English (LOTE) at home. Weighted sample data
were used in all the analyses reported in this article.
Harrison & McLeod: Risk and Protective Factors 515
Participants
A total of 4,983 children (2,537 boys; 2,446 girls) and
their parents participated in the kindergarten cohort of
the LSAC study. Children ranged in age from 4;3 (years;
months) to 5;7, but the majority (80%) were within a
6-month age span: 4;6 to 5;0 with a mean age of 56.91
months (SD = 2.64). Parents reported that over 96%
of children were attending an early childhood service
such as a child care center, preschool, or school (Harrison
& Ungerer, 2005; Harrison, Ungerer, et al., 2009). With
permission from parents, each child’s teacher was ap-
proached and asked to complete a brief questionnaire. A
total of 3,276 children’s teachers participated.
Measures
Outcome measures. Four outcome measures, devel-
oped and described in McLeod and Harrison (2009),
were used to determine childhood risk status for speech
and language impairment. These measures drew on mul-
tiple informants, including the child’s parent and teacher,
and direct assessment by a trained interviewer.
1. Parent report of expressive speech and language
concern based on the Parents’ Evaluation of Devel-
opmental Status (PEDS; Glascoe, 2000) question “Do
you have any concerns about how your child talks and
makes speech sounds?” (25.2% of the sample was
identified as impaired).
2. Parent report of receptive language concern based
on the PEDS question “Do you have any con-
cerns about how your child understands what you
say to him / her?” (9.5% of the sample was identified
as impaired).
3. Parent and teacher report of use of speech-language
pathology services in the past 12 months (14.5% of
the sample was identified as impaired).
4. Assessed scores of vocabulary comprehension on
the Adapted Peabody Picture Vocabulary Test—III
(PPVT–III; Rothman, 2003). Children were identi-
fied as having difficulty if they scored more than or
equal to 1 SD below the mean (14.7% of the sample
was identified as impaired).
There was a low-to-moderate overlap across these four
groups. For example, of the children whose parents were
concerned about their expressive speech and language
(Group 1), 27.2% had parents who were concerned about
receptive language, 43% were attending speech-language
pathology services, and 22.9% were in the low vocabulary
group. The use of four different outcome measures en-
abled examination of distinct contributions of risk and
protective factors to explain the disparate findings sum-
marized in Table 1.
516 Journal of Speech, Language, and Hearing Research • Vol. 53 • 508–529 • April 2010
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Risk and protective factors. Risk and protective fac-
tors identified by the U.S. Preventative Services Task
Force (Nelson et al., 2006; U.S. Preventative Services
Task Force, 2006) and our review of these and additional
studies (see Table 1) were matched to relevant items in
the LSAC dataset. All but the family history of speech
and language impairment were available. Television view-
ing was a risk factor that had not been considered in
previous studies but was added to the present study due
to its currency in public debate. A total of 31 potential
risk/protective factors were identified from parent report.
Child factors. Postnatal factors were described by
prematurity (defined as < 36 weeks of pregnancy), birth
weight (low birth weight defined as < 2500 g), whether
the child received neonatal intensive care, and the occur-
rence of multiple birth versus single birth. Medical con-
ditions identified by parents included ongoing problems
of asthma, bronchiolitis, and ear infections. Hearing sta-
tus was identified by the occurrence of ongoing hearing
problems. Oral sucking habits were described by whether
the child was breastfed for > 9 months. Child temper-
ament was assessed using the 12-item Short Tempera-
ment Scale for Children (STSC; Sanson, Prior, Garino,
Oberklaid, & Sewell, 1987). The STSC provides ratings
for three subscales: sociability (e.g., “This child is shy
when first meeting new children”), persistence (e.g.,
“This child stays with an activity [e.g., puzzle, construc-
tion kit, reading] for a long time”), and reactivity (e.g.,
“When shopping together, if I do not buy what this child
wants [e.g., sweets, clothing], he/she cries and yells”).
Items are scored on a scale from 1 = almost never to 6 =
almost always and combined to generate a mean score
for each subscale. Children’s proficiency in an LOTE
was described by two factors: regularly spoken to in a
language other than English and speaks a language other
than English in the home.
Parent factors. Demographic characteristics included
mother’s age at child’s birth and mother’s and father’s
years of education. Parental minority status or race was
recorded if either parent self-identified as being of Aborig-
inal or Torres Strait Islander background (indigenous
status). Parents’ language status was also self-identified
as “speaks a language other than English” (parents’
LOTE status). There were 40 different home languages
spoken by the parents in this study. English (86%) was
the main language spoken at home, followed by Arabic
(1.6%), Cantonese (1.3%), Vietnamese (1.0%), Mandarin
(0.8%), Greek (0.8%), Italian (0.7%), Samoan (0.5%),
Spanish (0.5%), Hindi (0.4%), and other languages. Such
cultural diversity is typical of the Australian population.
Maternal mental health was measured using the 6-item
screening version of the Kessler scale of nonspecific psy-
chological distress (K6; Kessler et al., 2002). The K6 is an
effective self-report measure for probing symptoms of
anxiety and depression and is a good predictor of mood
or anxiety disorders measuring concurrent mental state
(Furukawa, Kessler, Slade, & Andrews, 2003; Kessler
et al., 2003). Items (e.g., “In the past 4 weeks, how often
did you feel nervous?”) are rated on a 5-point Likert scale
(1 = none of the time, 5 = all of the time) and combined to
provide an overall mean score.
Family factors. SES was described by weekly house-
hold income, which was defined as combined yearly in-
come before tax. In addition, a specific index of family
financial hardship was determined by asking the pri-
mary parent whether he or she had experienced any
of seven different types of financial hardship in the past
12 months, such as “being unable to pay gas, electricity,
or telephone bills on time” or “going without meals.”
Summary categories of financial hardship were defined
by the total number of indices endorsed by the parent
(none, one, two, three, or more). Family size was described
by three related variables: the number of children in the
household and whether the LSAC child had older siblings
or had younger siblings. Home learning activities were
determined by asking the primary parent whether he
or someone in the household had provided any of seven
different types of learning support, such as reading to
the child, drawing or doing craft activities with the child,
or playing with the child (Australian Institute of Family
Studies, 2007). A weekly score was recorded for each in-
dex on a scale from 0 = none to 3 = every day and averaged
to generate an overall mean. Television watching were
reported by the primary parent as the number of hours
on typical weekdays and weekend days that the child
watches TV or videos. Scores ranged from 1 = does not
watch TVor videos to 5 = 5 hours or more. Smoking in the
household was recorded if either parent reported that
they smoked.
Community factors. Neighborhood disadvantage was
described by SEIFA score (ABS, 2003), which provides a
general indicator of neighborhood advantage or disadvan-
tage based on information collected in the 2001 census
for each postcode (zip code). A bivariate measure of com-
munity disadvantage was computed, with disadvantage
being equivalent to SEIFA scores > 1 SD below the mean.
Analysis Plan
Outcome measures were four binomial indicators of
speech/language risk: parent expressive language concern,
parent receptive language concern, use of speech-language
pathology services, and low vocabulary comprehension
score on the Adapted PPVT–III, each of which identified
a speech/language impairment group (impaired) and a non-
speech/language impairment group (nonimpaired). De-
scriptive analyses determined the frequency (n and % for
binomial variables) or mean scores (and SD for continuous
variables) for the 31 risk/protective factors for impaired
and nonimpaired groups on each of the four outcomes.
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Logistic regression analysis (Hosmer & Lemeshow,
1989) was used to examine the unique contribution of
each of these 31 risk/protective factors to the four mea-
sures of speech/language impairment, in which impair-
ment was coded as a binary variable (impaired = 1;
nonimpaired = 0). Results report the odds ratio (OR) for
each equation. ORs that are above 1.00 indicate that an
increase in the predictor increases the odds of impair-
ment, whereas ORs that are below 1.00 indicate that an
increase in the predictor decreases the odds of impair-
ment. The closer the OR is to 1.00, the smaller the effect
of the predictor. The criteria for significance ( p < .05) of
the OR are based on the ORs for the 95% confidence
interval (CI) not including 1.00; for example, OR = 1.24,
CI [1.05, 1.47] is significant, whereas OR = 1.22, CI
[0.83, 1.79] is not significant. A predictor with a sig-
nificant OR > 1.00 is considered to be a risk factor for
being in the impaired group, and a predictor with a sig-
nificant OR < 1.00 is considered to be a protective fac-
tor. See Tomblin et al. (1997) and Zubrick et al. (2007)
for further description of the application of ORs to the
field of speech-language pathology.
Multivariate logistic regression was then used to test
the effects of individual predictor variables after adjust-
ing multivariately for the effects of all other child-related,
parent-related, family, and community predictors. The
full set of variables identified as being significant pre-
dictors in bivariate analyses was entered in four sepa-
rate regression equations, one for each of the outcome
measures. These analyses assess the combined predic-
tive effect of the full set of variables, as reported by the
Model c2 and the Nagelkerke pseudo R2. The Nagelkerke
measure is an analog to the R2 produced by multivariate
linear regression and provides an approximation of the
percent of variance explained (Tabachnick & Fidell, 2001).
Effect size can be assessed by calculating the square-root
of the R2 and using Cohen’s (1988) guidelines: small effect
size, R = .1; medium, R = .3; large, R = .5. As noted pre-
viously, the effect of each individual variable in the model
is indicated by the OR. Results of the analyses also pro-
vide three additional statistics: the overall percent of
cases classified correctly; sensitivity or percent identifi-
cation of true positives (impaired group), being the num-
ber of true positives divided by true positives plus false
negatives; and specificity or percent identification of true
negatives (nonimpaired group), being the number of true
negatives divided by true negatives plus false positives.
Results
Bivariate Analyses
Table 2 presents the results of descriptive and logis-
tic regression analyses for each of the 31 risk and protective
factors for the four outcome measures: (a) parent-reported
Harrison & McLeod: Risk and Protective Factors 517
 Table 2. Bivariate descriptive statistics and logistic regression results for child, parent, family, and community predictors of children being in the speech and language impaired (impaired) and
518

non-speech and language impaired (nonimpaired) groups.

Journal of Speech, Language, and Hearing Research • Vol. 53 • 508–529 • April 2010

Outcome 1: Outcome 2: Outcome 3: Outcome 4:

Parent-reported expressive Parent-reported receptive Use of speech-language Low receptive vocabulary
speech and language concern language concern pathology services PPVT–III score < 1 SD
n = 4,980 to 3,197 n = 4,980 to 3,196 n = 4,179 to 3,183 n = 4,375 to 2,916

Impaired Nonimpaired Impaired Nonimpaired Impaired Nonimpaired Impaired Nonimpaired

Risk/protective LSAC n (%) or n (%) or OR n (%) or n (%) or OR n (%) or n (%) or OR n (%) or n (%) or OR
factors variable M (SD) M (SD) (95% CI) M (SD) M (SD) (95% CI) M (SD) M (SD) (95% CI) M (SD) M (SD) (95% CI)

Child factors
Sex Male 808 1,743 2.06 307 2,244 1.84 391 1,760 1.89 357 1,873 1.24
(64.4%) (46.8%) (1.80–2.35) (64.5%) (49.8%) (1.51–2.24) (64.6%) (49.2%) (1.58–2.56) (55.6%) (50.2%) (1.05–1.47)
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Postnatal Prematurity 77 152 1.55 37 193 1.88 47 150 1.95 33 162 1.22
factors (6.4%) (4.2%) (1.17–2.05) (8.0%) (4.4%) (1.31–2.71) (8.0%) (4.3%) (1.39–2.74) (5.4%) (4.5%) (0.83–1.79)
Birth weight 109 223 1.50 50 282 1.75 56 223 1.52 56 222 1.54
(< 2500 g) (8.9%) (6.1%) (1.18–1.91) (10.7%) (6.4%) (1.27–2.40) (9.3%) (6.3%) (1.12–2.07) (8.9%) (6.0%) (1.14–2.09)
Neonatal 231 513 1.41 109 635 1.81 114 517 1.38 103 543 1.12
intensive (18.5%) (13.8%) (1.19–1.68) (22.9%) (14.1%) (1.44–2.28) (18.9%) (14.5%) (1.11–1.72) (16.0%) (14.6%) (0.89–1.41)
care
Single vs. Multiple birth 39 101 1.14 13 127 0.94 20 103 1.16 23 96 1.40
multiple (3.1%) (2.7%) (0.78–1.66) (2.7%) (2.8%) (0.52–1.69) (3.3%) (2.9%) (0.72–1.89) (3.6%) (2.6%) (0.88–2.23)
births
Medical Asthma 296 754 1.22 127 924 1.41 169 733 1.49 145 787 1.10
conditions (23.6%) (20.3%) (1.04–1.42) (26.7%) (20.6%) (1.14–1.75) (27.9%) (20.6%) (1.23–1.82) (22.6%) (21.1%) (0.90–1.34)
Bronchiolitis 217 572 1.15 99 689 1.47 122 543 1.43 94 619 0.86
(17.5%) (15.5%) (0.97–1.37) (21.1%) (15.4%) (1.16–1.86) (20.4%) (15.3%) (1.15–1.77) (14.8%) (16.7%) (0.68–1.09)
Ear infections 145 254 1.78 76 323 2.46 74 263 1.75 57 287 1.17
(11.6%) (6.8%) (1.44–2.21) (16.0%) (7.2%) (1.88–3.22) (12.2%) (7.4%) (1.33–2.30) (8.9%) (7.7%) (0.87–1.57)
Hearing status Ongoing 96 71 4.27 64 102 6.67 55 86 4.09 28 105 1.60
hearing (7.6%) (1.9%) (3.12–5.84) (13.4%) (2.3%) (4.80–9.26) (9.1%) (2.4%) (2.88–5.80) (4.4%) (2.8%) (1.05–2.43)
problems
Oral sucking Breastfed for 446 1,533 0.79 122 1,855 0.49 208 1,487 0.74 208 1,570 0.65
habits/ > 9 months (35.9%) (41.4%) (0.69–0.90) (25.8%) (41.4%) (0.40–0.61) (34.7%) (41.8%) (0.61–0.89) (32.0%) (42.3%) (0.54–0.77)
breastfeeding
Temperament Persistence 3.64 3.99 0.69 3.29 3.97 0.50 3.67 3.94 0.76 3.61 3.97 0.68
(1.02) (0.93) (0.64–0.75) (1.10) (0.93) (0.45–0.56) (1.06) (0.94) (0.69–0.83) (1.01) (0.94) (0.62–0.75)
Reactivity 2.89 2.66 1.29 3.19 2.67 1.73 2.86 2.69 1.21 3.02 2.65 1.51
(1.00) (0.90) (1.20–1.39) (1.04) (0.91) (1.56–1.92) (1.01) (0.92) (1.10–1.32) (1.00) (0.90) (1.37–1.66)
Social 3.77 3.84 0.95 3.74 3.83 0.94 3.78 3.83 0.97 3.64 3.86 0.87
(1.20) (1.23) (0.90–1.01) (1.27) (1.22) (0.87–1.02) (1.25) (1.22) (0.90–1.04) (1.22) (1.22) (0.81–0.93)

(Continued on the following page)

 Table 2 Continued. Bivariate descriptive statistics and logistic regression results for child, parent, family, and community predictors of children being in the speech and language impaired
(impaired) and non-speech and language impaired (nonimpaired) groups.

Outcome 1: Outcome 2: Outcome 3: Outcome 4:

Parent-reported expressive Parent-reported receptive Use of speech-language Low receptive vocabulary
speech and language concern language concern pathology services PPVT–III score < 1 SD
n = 4,980 to 3,197 n = 4,980 to 3,196 n = 4,179 to 3,183 n = 4,375 to 2,916

Impaired Nonimpaired Impaired Nonimpaired Impaired Nonimpaired Impaired Nonimpaired

Risk/protective LSAC n (%) or n (%) or OR n (%) or n (%) or OR n (%) or n (%) or OR n (%) or n (%) or OR
factors variable M (SD ) M (SD) (95% CI) M (SD) M (SD) (95% CI) M (SD) M (SD) (95% CI) M (SD ) M (SD) (95% CI)
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Child factors
Languages Regularly 219 870 0.69 112 979 1.11 84 753 0.60 278 634 3.73
spoken spoken to (17.5%) (23.4%) (0.59–0.82) (23.6%) (21.7%) (0.89–1.39) (13.9%) (21.1%) (0.47–0.77) (43.3%) (17.0%) (3.13–4.46)
in LOTE
Speaks an 216 867 0.69 112 973 1.12 84 747 0.61 278 628 3.78
LOTE (17.2%) (23.3%) (0.58–0.81) (23.6%) (21.6%) (0.90–1.40) (13.9%) (20.9%) (0.48–0.78) (43.3%) (16.8%) (3.16–4.52)
Parent factors
Maternal age Maternal age 29.60 29.85 0.99 28.63 29.91 0.96 30.10 29.94 1.01 28.81 30.02 0.96
at birth at birth (5.48) (5.39) (0.98–1.10) (5.77) (5.36) (0.94–0.97) (5.59) (5.26) (0.99–1.02) (5.63) (5.22) (0.94–0.97)
of child of child
Educational level Mother ’s years 13.92 14.17 0.96 13.57 14.17 0.92 13.92 14.25 0.95 13.19 14.32 0.84
of parents of education (2.51) (2.68) (0.94–0.99) (2.34) (2.66) (0.89–0.95) (2.43) (2.63) (0.92–0.98) (2.54) (2.57) (0.81–0.87)
Father’s years 14.34 14.63 0.95 14.09 14.61 0.92 14.29 14.66 0.94 13.74 14.71 0.85
of education (2.42) (2.51) (0.93–0.98) (2.49) (2.49) (0.88–0.96) (2.48) (2.48) (0.91–0.98) (2.58) (2.42) (0.81–0.88)
Maternal mental Maternal 4.18 4.34 0.70 3.94 4.34 0.47 4.23 4.31 0.83 4.02 4.36 0.50
Harrison & McLeod: Risk and Protective Factors

health psychological (0.73) (0.61) (0.63–0.77) (0.81) (0.61) (0.41–0.53) (0.71) (0.63) (0.73–0.95) (0.84) (0.58) (0.44–0.57)
well-being
Minority status Parents’ 50 133 0.65 30 153 1.17 21 121 0.64 43 103 4.71
or race indigenous (4.0%) (3.6%) (0.54–0.79) (6.3%) (3.4%) (0.91–1.51) (3.5%) (3.4%) (0.48–0.85) (6.7%) (2.8%) (3.88–5.72)
status
Languages Parents’ LOTE 146 626 1.13 83 690 1.89 60 514 1.05 227 408 2.52
spoken and status (11.8%) (17.1%) (0.81–1.57) (17.8%) (15.6%) (1.26–2.85) (10.0%) (14.6%%) (0.66–1.67) (37.0%) (11.1%) (1.75–3.65)
proficiency
in English

(Continued on the following page)

519
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Journal of Speech, Language, and Hearing Research • Vol. 53 • 508–529 • April 2010

Table 2 Continued. Bivariate descriptive statistics and logistic regression results for child, parent, family, and community predictors of children being in the speech and language impaired
(impaired) and non-speech and language impaired (nonimpaired) groups.

Outcome 1: Outcome 2: Outcome 3: Outcome 4:

Parent-reported expressive Parent-reported receptive Use of speech-language Low receptive vocabulary
speech and language concern language concern pathology services PPVT–III score < 1 SD
n = 4,980 to 3,197 n = 4,980 to 3,196 n = 4,179 to 3,183 n = 4,375 to 2,916

Impaired Nonimpaired Impaired Nonimpaired Impaired Nonimpaired Impaired Nonimpaired

Risk/protective LSAC n (%) or n (%) or OR n (%) or n (%) or OR n (%) or n (%) or OR n (%) or n (%) or OR
factors variable M (SD ) M (SD) (95% CI) M (SD) M (SD) (95% CI) M (SD) M (SD) (95% CI) M (SD ) M (SD) (95% CI)
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Family factors
Socioeconomic Household 9.95 10.33 0.95 9.27 10.34 0.87 10.11 10.39 0.96 9.00 10.53 0.82
factors income (2.88) (2.71) (0.93–0.98) (2.79) (2.73) (0.84–0.90) (2.62) (2.70) (0.93–0.995) (2.72) (2.64) (0.79–0.84)
Financial Financial 0.69 0.57 1.27 0.85 0.57 1.65 0.63 0.56 1.15 0.78 0.55 1.53
hardship hardship (0.74) (0.70) (1.16–1.38) (0.76) (0.70) (1.46–1.87) (0.71) (0.70) (1.02–1.30) (0.78) (0.69) (1.37–1.72)
Family size Number of 2.54 2.50 1.03 2.47 2.51 0.97 2.50 2.48 1.02 2.88 2.44 1.41
children (1.08) (1.06) (0.97–1.10) (1.11) (1.06) (0.88–1.06) (0.98) (1.03) (0.94–1.11) (1.34) (0.98) (1.31–1.51)
in the
household
Older siblings 773 2,154 1.17 249 2,679 0.75 378 2,066 1.22 418 2,154 1.36
(61.6%) (57.8%) (1.03–1.34) (52.4%) (59.5%) (0.62–0.91) (62.5%) (57.8%) (1.02–1.46) (65.0%) (57.7%) (1.15–1.62)
Younger 573 1,725 0.98 234 2,063 1.15 277 1,654 0.98 321 1,729 1.15
siblings (45.7%) (46.3%) (0.86–1.10) (49.3%) (45.8%) (0.95–1.39) (45.9%) (46.3%) (0.83–1.17) (49.9%) (46.3%) (0.98–1.36)
Home learning Support for 1.69 1.71 0.92 1.61 1.71 0.71 1.74 1.70 1.16 1.57 1.74 0.57
activities children’s (0.55) (0.55) (0.82–1.03) (0.57) (0.55) (0.60–0.84) (0.54) (0.55) (0.99–1.35) (0.55) (0.55) (0.49–0.67)
learning
Television TV watching 3.13 3.04 1.20 3.17 3.05 1.26 3.12 3.05 1.15 3.16 3.03 1.29
watching (weekdays) (0.73) (0.72) (1.09–1.31) (0.81) (0.71) (1.10–1.43) (0.71) (0.72) (1.02–1.29) (0.80) (0.70) (1.14–1.45)
TV watching 3.06 2.99 1.10 3.13 3.00 1.21 3.09 3.00 1.13 3.15 2.98 1.28
(weekends) (0.86) (0.83) (1.02–1.18) (0.93) (0.83) (1.08–1.35) (0.83) (0.82) (1.02–1.26) (0.95) (0.80) (1.15–1.41)
Smoking in the Smoking in the 154 440 1.05 84 508 1.76 88 496 1.12 133 372 2.73
household household (14.7%) (14.2%) (0.86–1.28) (21.5%) (13.5%) (1.36–2.28) (15.4%) (14.0%) (0.88–1.43) (26.2%) (11.5%) (2.18–3.42)
Community factors
Neighborhood SEIFA > 1 SD 186 528 1.05 88 626 1.41 79 512 0.90 127 476 1.69
disadvantage below mean (14.8%) (14.2%) (.88–1.26) (18.5%) (13.9%) (1.10–1.80) (13.1%) (14.3%) (0.70–1.16) (19.8%) (12.8%) (1.36–2.10)

Note. PPVT–III = Adapted Peabody Picture Vocabulary Test—III (Rothman, 2003); LSAC = The Longitudinal Study of Australian Children (Sanson et al., 2002); LOTE = language other than English;
SEIFA = Socio-Economic Indexes for Areas (Australian Bureau of Statistics, 2003). Significant outcomes (p < .05) are indicated by bold type.
expressive speech and language concern, (b) parent-reported
receptive language concern, (c) use of speech-language
pathology services, and (d) low vocabulary comprehen-
sion (score < 1 SD below the mean on the Adapted
PPVT–III). An examination of the ORs and CIs for these
analyses showed that all but 2 of the 31 predictor vari-
ables were significant predictors of at least one measure
of speech/language impairment. Twenty-two variables
were significant for three or four of the four outcome mea-
sures. Risk factors for the child were being male, having
a history of perinatal complications (prematurity, low birth
weight, use of neonatal intensive care), having past and
ongoing medical conditions (asthma, ear infections, hear-
ing problems), having a more reactive temperament, and
having older siblings. Higher levels of financial hardship
and more weekend and weekday television viewing were
family risk factors for all four outcomes. Protective factors
for the child were being breastfed for > 9 months and
having a more persistent temperament. Family protec-
tive factors were mothers and fathers having completed
more years of education, higher levels of maternal psy-
chological well-being, and higher household income. Pre-
dictors that were identified as both a risk and a protective
factor for different outcomes were the child speaking or
being spoken to in LOTE, and parents’ being of indig-
enous background or speaking LOTE. A further seven
variables were identified as significant predictors for
one or two of the outcomes: childhood bronchiolitis (risk),
greater temperamental sociability (protective), older ma-
ternal age at birth (protective), larger family size (risk),
greater support for children’s learning in the home (pro-
tective), smoking in the household (risk), and living in a
more disadvantaged neighborhood (risk). Two predic-
tors, being a multiple birth and having younger siblings,
were not significant for any of the four outcomes.
Multivariate Analyses
Multivariate logistic regressions were used to test the
above predictor variables collectively. Variables that were
found to be nonsignificant in bivariate tests were excluded.
Highly intercorrelated variables were either represented
by a single variable (e.g., child speaking or being spoken to
in LOTE was dropped and parents’ LOTE status was re-
tained) or combined (e.g., weekday and weekend television
viewing were summed). This process left 26 factors, which
were included in four separate multivariate logistic re-
gression analyses. Results are presented in Table 3.
Significant predictors for Outcome 1: Expressive speech
and language concern. Of the 26 putative risk /protective
factors included in the model, 8 achieved significance as
a predictor of parent-reported expressive speech and
language concern (impaired group). Increased odds for
being in the impaired group were associated with the
following risk factors: being male (OR = 1.97), having
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ongoing problems with ear infections (OR = 1.41) and
hearing problems (OR = 3.18), having a more reactive
temperament (OR = 1.13), and having older siblings
(OR = 1.26). Reduced odds for being in the impaired
group were associated with the following protective
factors: having a more persistent temperament (OR =
0.75), mothers having higher ratings for psychological
well-being (OR = 0.74), and parents speaking an LOTE
(OR = 0.52). The full model accounted for 11.7% ( pseudo
R2 = .117) of the variance, which is equivalent to a me-
dium effect size (R = .34; Cohen, 1988). In comparison,
Reilly et al. (2007), using multivariate linear regression
and a smaller set of significant predictors (4), reported
a lower proportion of the explained variance (6.4% and
7.0%) for mothers’ ratings of their 2-year-olds’ speech and
expressed vocabulary. The proportion of cases classified
correctly was relatively low (76.5%). Although the model
had high specificity (97.7% of nonimpaired cases were
correctly identified), it had poor sensitivity (11.3% of im-
paired cases were correctly identified).
Significant predictors for Outcome 2: Receptive lan-
guage concern. Seven variables were significant predic-
tors for parental report of receptive language concern.
Increased odds were evident for the following risk
factors: being male (OR = 1.39), having ongoing hearing
problems (OR = 4.43), and having a more reactive tem-
perament (OR = 1.47). Reduced odds were evident for the
following protective factors: being breastfed for > 9 months
(OR = 0.70), having a more persistent temperament (OR =
0.54), mothers having higher ratings for psychological
well-being (OR = 0.66), and the presence of older siblings
(OR = 0.67). The full model accounted for 21.5% of the
variance. This is equivalent to a moderate-to-large effect
size (R2 = .215, R = .46; Cohen, 1988). The proportion of
cases classified correctly was relatively high (91.8%), but
this was due to the model’s high specificity (99.5% of
nonimpaired cases were correctly identified). The model
had poor sensitivity (9.8% of impaired cases were cor-
rectly identified).
Significant predictors for Outcome 3: Attendance at
speech-language pathology. Ten predictors were associ-
ated with children’s attendance at speech-language pa-
thology. Increased odds were noted for being male (OR =
1.71), being premature (OR = 1.84), having asthma (OR =
1.33), having ongoing hearing problems (OR = 2.95),
having older siblings (OR = 1.39), and spending more
time watching television (OR = 1.10). Increased odds were
also seen for home support for learning (OR = 1.36), with
more support being associated with greater likelihood of
being in the impaired group. This finding is difficult to
explain in that it may reflect the use of speech-language
pathology services by parents who are also more sup-
portive of their children’s learning, but equally it may
reflect the additional support that parents are provid-
ing at home as a result of their children attending
Harrison & McLeod: Risk and Protective Factors 521
Table 3. Multivariate logistic regression: adjusted odds ratio and cumulative amount of variance (pseudo R2) for child, parent, family, and
community predictors of speech and language impairment.

Outcome 1:
Parent-reported Outcome 2: Outcome 3: Outcome 4:
expressive speech Parent-reported Use of speech- Low receptive
and language receptive language language pathology vocabulary
concern concern services PPVT < 1 SD
Model Model Model Model
c2(26, N = 3,197) = c2(26, N = 3,196) = c2(26, N = 3,183) = c2(26, N = 2,916) =
256.22; 314.05; 164.93; 369.63;
pseudo R2 = .117 pseudo R2 = .215 pseudo R2 = .092 pseudo R2 = .239
LSAC identifier Adjusted OR (p) Adjusted OR (p) Adjusted OR (p) Adjusted OR (p)

Child factors
Male 1.97 (<.001) 1.39 (.025) 1.71 (<.001) 1.29 (.055)
Premature 1.17 (.549) 1.59 (.222) 1.84 (.035) .86 (.711)
Birth weight (<2500 g) 1.04 (.863) .87 (.687) 1.14 (.612) 1.61 (.127)
Neonatal intensive care 1.00 (.976) .96 (.824) .90 (.513) .94 (.767)
Breastfed for > 9 months .87 (.147) .70 (.022) .83 (.101) .89 (.387)
Asthma 1.01 (.930) 1.15 (.414) 1.33 (.024) 1.12 (.491)
Bronchiolitis .97 (.818) 1.21 (.279) 1.06 (.680) .96 (.825)
Ear infections 1.41 (.024) 1.38 (.136) 1.30 (.141) 1.27 (.319)
Ongoing hearing problems 3.18 (<.001) 4.43 (<.001) 2.95 (<.001) 1.32 (.423)
Temperament: Social .94 (.105) .98 (.676) .91 (.038) .86 (.007)
Temperament: Persistence .75 (<.001) .54 (<.001) .79 (<.001) .82 (.005)
Temperament: Reactivity 1.13 (.012) 1.47 (<.001) 1.11 (.084) 1.19 (.018)
Parent factors
Maternal age at birth of child 1.00 (.805) 1.00 (.852) 1.02 (.078) .96 (.004)
Mother’s years of education 1.00 (.979) .95 (.155) 1.00 (.935) .91 (.002)
Father’s years of education .99 (.559) 1.02 (.609) .98 (.320) .96 (.167)
Maternal psychological distress/well-being .74 (<.001) .66 (<.001) .92 (.348) .78 (.014)
Parents’ LOTE status .52 (<.001) 1.20 (.370) .55 (.002) 5.60 (<.001)
Parents’ indigenous status .88 (.615) .99 (.987) .81 (.502) 1.14 (.711)
Family factors
Household income .99 (.614) .98 (.636) .97 (.321) .91 (.004)
Financial hardship 1.03 (.670) 1.13 (.262) 1.06 (.547) 1.01 (.931)
Number of children in the household 1.01 (.864) .94 (.469) .93 (.276) 1.43 (<.001)
Older siblings 1.26 (.032) .67 (.017) 1.39 (.012) .88 (.411)
Support for children’s learning at home 1.15 (.100) .99 (.946) 1.36 (.004) .68 (.002)
TV watching (weekdays + weekends) 1.05 (.138) 1.02 (.719) 1.10 (.020) 1.03 (.516)
Smoking in the household .92 (.555) 1.35 (.118) 1.04 (.801) 1.69 (.002)
Community factors
SEIFA > 1 SD below mean .88 (.284) 1.19 (.332) .83 (.209) 0.94 (.719)
Proportion of cases classified correctly 76.5% 91.8% 85.8% 89.6%
Sensitivity 11.3% 9.8% 2.6% 15.8%
Specificity 97.7% 99.5% 99.7% 99.0%

Note. Pseudo R2 is calculated according to Nagelkerk, as provided by the SPSS output. Significant outcomes (p ≤ .05) are indicated by bold type.

speech-language pathology. Reduced odds were seen
for the following protective factors: possessing a more
sociable and more persistent temperament (ORs = 0.91
and 0.79) and parents speaking an LOTE (OR = 0.55).
The combined set of predictors accounted for 9.2% of the
variance for attendance at speech-language pathology
(R2 = .092, R = .30). The lower figure for this outcome
(although still equivalent to a medium effect size) is likely
due to additional factors, such as the availability and
affordability of speech-language pathology, which were
not assessed. The proportion of cases classified correctly
was 85.8%, with high specificity (99.7% of nonimpaired
cases were correctly identified) but poor sensitivity (2.6%
of impaired cases were correctly identified).

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 Significant predictors for Outcome 4: Low score on
Adapted PPVT–III. The largest number of significant
predictors (12) was identified for having a low assess-
ment score (< 1 SD below the mean) on the Adapted
PPVT–III. Increased odds for being in the identified
group were associated with five risk factors: being male
(OR = 1.29), having a more reactive temperament (OR =
1.19), parents speaking an LOTE (OR = 5.60), having
more children in the household (OR = 1.43), and parental
smoking in the household (OR = 1.69). Reduced odds were
associated with the following protective factors: the
child having a more sociable and persistent tempera-
ment (ORs = 0.86 and 0.82); mothers being older at the
birth of child (OR = 0.96), having more years of edu-
cation (OR = 0.91), and reporting higher levels of
psychological well-being (OR = 0.78); a higher house-
hold income (OR = 0.91); and parents providing more
home support for learning (OR = 0.68). The full model
accounted for almost one-quarter (23.9%) of the var-
iance (R2 = .239, R = .49), which was equivalent to
a moderate-to-large effect size. The proportion of cases
classified correctly was 89.6%, with high specificity
(99.0% of nonimpaired cases were correctly identified)
and low sensitivity (15.8% of impaired cases were cor-
rectly identified).
The variance explained was similar to that noted for
the association for parent-reported receptive language
concern (R2 = .215, R = .46); however, the pattern of
predictors was notably different. Low scores on assessed
receptive vocabulary were strongly associated with envi-
ronmental indicators (parent, family, and community);
however, parent-rated concern was primarily associ-
ated with child-related factors. In addition, the presence
of ongoing hearing problems was highly significant for
parent-rated but not assessed poor receptive vocabulary
(OR = 4.43, p < .001 vs. OR = 1.32, p = ns), and parents’
LOTE status was highly significant for assessed but
not parent-rated low receptive vocabulary (OR = 5.60,
p < .001 vs. OR = 1.20, p = ns).
The discrepancy in results for parents’ LOTE status
is likely due to the influence of the primary language
being assessed in each outcome measure. The Adapted
PPVT–III assessed competency in English, whereas
parents were reporting on the child’s first and other
languages in the outcome measures of receptive and
expressive language concern. This was most notable for
parent-reported expressive language concern, in which
LOTE status was a protective factor (OR = 0.52). The
discrepancy in results for ongoing hearing problems
may also be due to parents’ interpretation of the ques-
tion “Do you have any concerns about how your child
understands what you say to him?” which could be in-
terpreted as “hearing what you say” or “understanding
the language you use.”
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Discussion
Recent conceptualizations of child functioning
(World Health Organization, 2007) acknowledge that
biological, psychosocial, and societal factors interactively
influence development. Understanding and explicating
the underlying contributors to childhood speech and lan-
guage impairment, therefore, requires consideration of
multiple attributes of the individual as well as of the
family and social contexts, each of which may expose the
child to risk or protection. The present study has applied
this model (Bronfenbrenner, 2005) to investigate child,
parent, family, and community predictors of speech and
language impairment in a nationally representative sam-
ple of 4- to 5-year-old children. Speech and language
impaired versus nonimpaired status was described by
four distinct measures: parent-reported expressive and
receptive language concern, teacher- and parent-reported
use of speech-language pathology services, and assessed
receptive vocabulary. Results for these four outcomes
identified a core set of significant predictors related to
child factors (being male; having ongoing hearing prob-
lems; and having a less persistent, less sociable, and
more reactive temperament), parent factors (mothers with
a lower sense of psychological well-being, parents speak-
ing languages other than English), and family factors
(support for children’s learning at home, the presence of
older siblings). Table 4 provides a summary of these ef-
fects and their direction (risk or protection). The first six
rows indicate the factors that were consistently associ-
ated with all four indicators of speech and language im-
pairment; the remaining rows show where discrepancies
were noted in the direction of the effects.
These and other results presented in this study add
to existing knowledge that may be useful for primary
care professionals seeking to identify children at risk,
who may require specialist assessment of their speech
and language development or who would benefit from
early intervention. The findings from this investigation
confirmed that childhood speech and language impair-
ment is influenced by multiple factors. Each of these is
discussed in turn.
Child Factors
Being male was a significant risk factor for all four
outcome measures: parental concern regarding expres-
sive as well as receptive speech and language difficulties,
having a low score for receptive vocabulary, and attending
speech-language pathology services (ORs of 1.29–1.97).
These findings were not surprising considering previous
research (reviewed earlier in this article), but they do
confirm an identifiable risk at an age when most boys are
attending an early childhood education program (Harrison
& Ungerer, 2005). A message that boys are at risk for
Harrison & McLeod: Risk and Protective Factors 523
 Table 4. Consistent risk and protective factors relating to speech and language impairment in a nationally representative sample of 4- to
5-year-olds.

Outcome 1: Outcome 2: Outcome 3: Outcome 4:

Expressive speech Receptive Attend Low score
and language language speech-language on Adapted
Risk/Protective factor concern concern pathology PPVT–III

Male Risk Risk Risk Risk

Ongoing hearing problems Risk Risk Risk
Temperament: Social Protective Protective
Temperament: Persistence Protective Protective Protective Protective
Temperament: Reactivity Risk Risk Risk
Maternal psychological well-being Protective Protective Protective
Parents’ status regarding languages other than English spoken Protective Protective Risk
Older siblings Risk Protective Risk
Support for children’s learning at home Risk Protective

poorer speech and language should be strongly imparted
to primary care professionals, including early childhood
teachers, who are in a position to recommend referral for
speech/language assessment.
Having ongoing hearing problems was also an im-
portant risk factor, particularly for expressive and recep-
tive language as reported by parents and for receipt of
speech-language pathology support. Results showed that
children with ongoing hearing problems were three times
more likely to be identified with expressive speech and
language difficulties and to be attending speech-language
pathology (ORs = 3.19 and 2.96) and four times more
likely to have difficulties with receptive language ability
than their nonaffected peers (OR = 4.43). These results
confirm work by Yliherva et al. (2001) that included on-
going hearing problems as a predictor for speech and
language impairment in a similarly large-scale study
of Finnish children. Both studies support the need for
infant hearing screening programs that can assist with
early identification of children with hearing problems
and have the potential to reduce the observed risk to
childhood speech and language.
Child medical conditions that predicted at least one
of the four speech/language outcomes were asthma, which
was identified as increasing risk for attendance at speech-
language pathology (OR = 1.33), and ongoing ear in-
fections, which were a risk for expressive speech and
language concern (OR = 1.41).
A protective factor for receptive language was being
breastfed for > 9 months (OR = 0.70). Although this was
included as an indicator of oral sucking habits, with
benefits for children’s oromuscular development, pro-
longed breastfeeding is also likely to be influenced by
and interact with parental and family factors, such as
maternal well-being and socioeconomic status.
Child temperament characteristics were an impor-
tant and consistent predictor of speech and language
impairment, being associated with all four outcomes.
Children with a more persistent temperament (i.e., able
to stay on task, keep on trying and do not give up easily)
were less likely to have difficulties with speech and lan-
guage (ORs of 0.54–0.82). Previous work by Hauner et al.
(2005) has also shown that “decreased task persistence or
attention” (p. 635) was a significant risk factor for speech
impairment. On the other hand, a more reactive temper-
ament was associated with greater risk of speech and
language impairment (ORs of 1.13–1.47). Similar find-
ings were noted by Hauner et al. (2005) who described
“approach-related or withdrawal-related negative affect,
negative emotionality or mood” (p. 635) as a significant
risk factor for increased severity of speech impairment.
Reactivity in young children has been associated with
inhibition and fearfulness in novel situations, impulsiv-
ity, and behavioral dysregulation (see Sanson, Hemphill,
& Smart, 2004), all of which could tend to impede speech
and language acquisition. Temperamental sociability, on
the other hand, was associated with a reduced risk of
speech and language impairment (ORs = 0.91 and 0.86).
Sociable children tend to have more positive social rela-
tions and be more popular with friends (Sanson et al.,
2004), characteristics that are likely to enhance speech
and language development. Prior et al. (2008) found that
shy children were at increased risk for communication
difficulties; however, the authors stated it was unknown
whether shyness affected the child’s initiation and respon-
siveness in conversation or whether poor communication
led to the child’s shyness.
Parent Factors
Among the risks and protective factors associated
with the child’s home environment, maternal psycholog-
ical well-being was consistently found to positively im-
pact children’s expressive and receptive language (ORs =
0.66–0.78). Conversely, children did less well when their

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mothers reported more symptoms of anxiety and de-
pression. The sociofamilial environment, particularly
language stimulation and responsivity, is an important
context for the development of language skills (Desmarais,
Sylvestre, Meyer, Bairati, & Rouleau, 2008). It has been
hypothesized that maternal well-being facilitates language
stimulation in the home and conversely that maternal
psychological distress or depression reduces language
stimulation (Prior et al., 2008).
The home language environment was a further pre-
dictor of speech and language impairment; however, as
discussed in the previous section, the direction of re-
sults differed by the outcome being measured. Parents who
spoke an LOTE reported less concern about their child’s
expressive speech and language ability (OR = 0.52), but
on the other hand, these children were more likely to be
in the low scoring group for English receptive vocabulary
(OR = 5.60), a discrepancy likely due to the parent
reporting on all of the languages spoken by the child, not
just English. Children of parents who spoke an LOTE
were also less likely to be attending speech-language
pathology (OR = 0.55), but the reduced use of speech-
language pathology could be due to cross-cultural dif-
ferences in definitions of disability and differences in
accessing professional services (cf. Hwa-Froelich & Westby,
2003). When comparing these results to previous findings,
it is important to note that several studies that have
examined risk factors have specifically excluded children
with bilingualism (e.g., Fox et al., 2002; Tallal et al.,
1989). Three studies found increased risk for speech/
language impairment in nondominant language speakers
within examined societies that were English-dominant
(Reilly et al., 2007), French-dominant (Chevrie-Muller
et al., 2005), and Dutch-dominant (Peters et al., 1997).
However, other research (summarized in Table 1) has
shown mixed results for the impact of proficiency in
home language and minority status or race. In the pre-
sent study, the inclusion of four distinct outcome mea-
sures has enabled the current research to examine some
of the discrepancies in the results of these studies.
Family Factors
The presence of siblings is a further feature of the
home environment that was expected to impact child-
hood speech and language impairment. In the present
study, only having an older sibling had a significant
effect, being a risk for expressive speech and language
concern and for attending speech-language pathology
(ORs = 1.26 and 1.39) and a protective factor for recep-
tive language concern (OR = 0.67). These findings pro-
vide some evidence to support the suspicion, often noted
in clinical folklore, that older siblings are more verbal
(i.e., use more “air time”) than younger siblings and
speak on behalf of their younger siblings. Relatedly,
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Barr, McLeod, and Daniel (2008) found that typically
developing children who are a sibling of a child with a
communication impairment can be worried, protective,
and act as an interpreter for their sibling. The benefit
is that younger siblings hear rich language from their
older siblings as well as their parents and therefore do
not have receptive language difficulties. The finding that
having younger siblings was neither a significant risk
nor a protective factor is further evidence to support these
speculations.
Children’s access to a supportive home-learning en-
vironment was a protective factor for assessed receptive
vocabulary (OR = 0.68). This result, along with maternal
age and years of education, family income, and house-
hold size, suggest that children from more advantaged
families with parents who were more involved in their
children’s learning were less likely to be classified as
having poor receptive vocabulary (on the Adapted
PPVT–III). The result is consistent with other findings
for the LSAC children linking sociodemographic vari-
ables (education, income, occupation, SEIFA) and sup-
port for home learning with enhanced learning outcomes
(Wake et al., 2008) and with recent findings from the
United States linking higher SES backgrounds with
greater vocabulary at school entry (Rowe & Goldin-
Meadow, 2009).
Smoking in the household was a significant risk fac-
tor for low scores on the Adapted PPVT–III (OR = 1.68).
A similar finding was noted for kindergarten children
studied by Tomblin et al. (1997) but not for 2-year-olds
(Zubrick et al., 2007).
Television watching is a variable that had not been
assessed in previous studies. Bivariate analyses identi-
fied more time spent in television watching as a signif-
icant risk for all four outcomes; however, it was only
retained for the use of speech-language pathology ser-
vices (OR = 1.10) in the multivariate analyses. It is not
clear whether the amount of TV watching affected the
child’s ability to engage in communication or whether
poor communication skills led to the increase in TV
watching.
Strengths
To summarize, the strengths of the current study
include the size of the Longitudinal Study of Australian
Children (LSAC) sample, the use of population sampling
to represent all 4- to 5-year-olds in Australia, the in-
clusion of a broad range of potential risk and protective
factors, and the concurrent testing of the effects of these
factors using a multivariate design. The current study
also included new and rarely studied variables such as
child temperament and features of the home environ-
ment such as television watching and smoking in the
household. Furthermore, by using and comparing findings
Harrison & McLeod: Risk and Protective Factors 525
for four speech and language outcome measures, this
study has enabled a deeper consideration of some of the
complexities involved in the processes influencing speech
and language acquisition.
This study adds to the growing number of large-
scale studies that are examining the ways that biological
and environmental factors explain or influence speech
and language development in early childhood (Reilly et al.,
2006, 2007; Zubrick et al., 2007). The results of recent
research with children under 2 years of age have sug-
gested that biological trajectories are the primary drivers
of early communication and vocabulary development
(Zubrick et al., 2007) and that social and environmental
factors have a minimal effect (e.g., explaining less than
7% of the variance; Reilly et al., 2009). Findings presented
here are consistent with this work, in that factors intrin-
sic to the child (sex, temperament) or related to neuro-
biological mechanisms (prematurity, low birth weight,
perinatal difficulties) were significant predictors of speech
and language impairment. However, ongoing medical con-
ditions, which are likely to be affected by social and envi-
ronmental conditions, were also important and consistent
predictors, as were other factors related to the family en-
vironment. The overall impression from the present study
is that psychosocial and socioeconomic factors do con-
tribute to childhood speech and language development,
at least at age 4–5 years. The variance explained for
expressive and receptive language (11.7%, 21.5%, and
23.9%) was considerably larger than reported by Reilly
et al. (2009) for 2-year-olds. This suggests that screening
for child and family risk factors in combination with ob-
servations or informal testing of children’s speech and
language ability and vocabulary growth in relation to de-
velopmental norms is likely to provide the best means of
identifying children who need referral to speech-language
pathology or specialist early intervention.
Limitations
The limitations of the current study relate to the
measures that were possible to collect in a large multi-
dimensional study such as LSAC. Only one of the out-
comes was based on direct assessment of the children
(Adapted PPVT–III). Two of the outcomes were based
on parent report of concern, and although the validity
of two outcomes has been confirmed (Harrison, McLeod,
Berthelsen, & Walker, 2009; McLeod & Harrison, 2009),
these should be considered a screening measure rather
than representing a comprehensive assessment. A further
limitation is the lack of information pertaining to fam-
ily history of speech and language impairment. This is
an important predictor, which would likely add to the
variance explained. The large amount of unexplained
variance is acknowledged as a limitation; however, we
note that other multivariate analyses of the LSAC data
526 Journal of Speech, Language, and Hearing Research • Vol. 53 • 508–529 • April 2010
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set (predicting other child outcomes) have reported sim-
ilar figures (10%–25%, Harrison, Ungerer, et al., 2009;
7%–20%, Wake et al., 2008). The multivariate logistic
regression results for proportion of cases classified cor-
rectly, sensitivity, and specificity also point to limita-
tions in the predictive power of this approach. The set of
predictor variables did not correctly identify impaired
cases (low sensitivity), although there was a high level
of specificity (correctly identified nonimpaired cases).
Conclusion
This study has extended previous work on identifi-
cation of risk and protective factors for childhood speech
and language impairment by using a large, nationally
representative sample of 4- to 5-year-old children. A
comprehensive range of predictor variables was used,
including previously unexplored or underexplored vari-
ables. The multivariate design enabled testing of the
collective contribution of these predictors. When the full
set of child, parent, family, and community variables was
included in the model, many of the variables identified as
significant predictors in bivariate analyses were elimi-
nated due to overlapping of underlying constructs. Nine
factors were consistently identified in multivariate anal-
yses as having a unique effect on speech and language
impairment: being male (risk), having ongoing hearing
problems (risk), having a more reactive temperament
(risk), having a more persistent temperament (protec-
tive), having a more social temperament (protective), in-
creased maternal well-being (protective), having an older
sibling (risk/protective), parental LOTE status (risk/
protective), and support for children’s learning in the
home (risk/protective). These early risk and protective
factors along with observations of children’s speech and
language milestones can be a useful guide for primary
care professionals seeking to identify children who ben-
efit from early intervention communication programs.
Acknowledgments
This research was supported by the following sources:
Australian Research Council Discovery Grant DP0773978
and the Charles Sturt University Research Institute for
Professional Practice, Learning, and Education. An earlier
version of a portion of this article was presented at the 2008
Conference of the International Clinical Linguistics and
Phonetics Association in Istanbul, Turkey. The authors would
like to acknowledge the contribution of the Australian Rotary
Health Fund and Foundation for Children Research Grant
and the members of the Longitudinal Study of Australian
Children Research Consortium: John Ainley, Donna Berthelsen,
Michael Bittman, Linda Harrison, Ilan Katz, Jan Nicholson,
Bryan Rodgers, Ann Sanson, Michael Sawyer, Sven Silburn,
Lyndall Strazdins, Judy Ungerer, Graham Vimpani, Melissa
Wake, and Stephen Zubrick.
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