Contributing Factors in

Children At Risk for

Speech/Language Delays
Kim Fitzgerald and Megan Safley
Truman State University
November 19, 2009
Review of the Literature
Specific Language Impairment
„ La Paro, Justice, Skibbe, & Pianta (2004)
„ National Institute of Child Health and Human
Development Study of Early Child Care database
of 1,364 children
„ 73 children identified as exhibiting specific
language impairment (SLI)
„ Logistic regression analysis conducted to identify
predictive factors for if the SLI was resolved or
unresolved by age 4 years, 6 months
Specific Language Impairment
„ Important factors in logistic regression
model:
„ Maternal sensitivity
„ Maternal depression
„ Child externalizing behavior
„ Child health
„ Income-to-needs ratio
„ Home environment
SLI Logistic Regression Model
Predicted
Actual Resolved Unresolved % Correct
Resolved 22 11 66.8%
Unresolved 10 30 75.0%
Overall 71.2%

(LaParo , et al., 2004)

Late Language Emergence
„ Zubrick, Taylor, Rice, Slegers (2007)
„ 1,766 two-year-old children from the
Randomly Ascertained Sample of Children
born in Australia’s Largest State
(RASCALS) database
„ Demographically similar to Midwestern U.S.
„ Data collected via a postal questionnaire
Late Language Emergence
„ For this study, late language emergence
(LLE) defined as failing the ASQ
Communication section
„ Differences between children with and
without LLE were identified
„ Logistic regression analysis was used to
determine predictive factors
Late Language Emergence
„ Significant predictors included:
„ Family history of LLE
„ Larger family size
„ Failing the ASQ Fine Motor, Gross Motor,
Adaptive, and/or Personal Social sections
„ Failing the Internal, External, and/or Total Score
of the Child Behavior Checklist
„ Prematurity
Late Language Emergence
„ Variables not identified as predictive:
„ Maternal education
„ Maternal depression
„ Socioeconomic status
Ages and Stages Questionnaire
„ Research on validity and reliability
„ Over 7,000 questionnaires were analyzed
„ Reliability measured as % agreement
between classifications
„ Test-retest reliability was 94% at a 2-week
interval
„ Inter-observer reliability (parent vs.
professional) was 94%
Ages and Stages Questionnaire
„ Scoring criteria determined to maximize sensitivity
and specificity but minimize over-referral and
under-referral
„ Concurrent validity measured by comparing ASQ
classification with child’s performance on:
„ The Revised Gesell and Armatruda Developmental and
Neurological Examination
„ the Bailey Scales of Infant Development
„ the Stanford-Binet Intelligence Test 4th-Edition
„ the McCarthy Scales of Children’s Abilities
Statement of Problem
„ Are there certain factors that put a child at risk for
a speech/language delay?
„ If there are certain factors, how can we prevent at
risk children from needing intervention?
„ In our field, are we overlooking certain factors that
put a child at risk for a delay?
„ Do we focus too much on factors that do not put a
child at risk?
Research Purpose
„ The purpose of this project was to
determine, using a regression analysis, the
factors that have the most impact on
whether or not a child is at risk for a
speech/language delay, as determined by
the Fluharty-2 Preschool Speech and
Language Screening Test.
 Research
Methodology
Consent Forms
„ Parent consent form: parent gave consent
to complete the questionnaires
„ Child consent form: parent gave consent
for the Fluharty-2 to be administered to
their child
Developing the Questionnaire
„ Developed list of factors we thought would
be important
„ Considered factors used in previous
studies
„ Formulated questions in a clear and
concise way for the parents to answer
Questions Included
„ Child’s age
„ Child’s ethnicity
„ Child’s gender
„ Father’s age at birth
„ Mother’s age at birth
„ Length of pregnancy
„ Birth weight
Questions Included
„ Mother’s level of education
„ Father’s level of education
„ Mother’s level of depression
„ Father’s level of depression
„ Hours in paid employment per week (for
each parent)
„ Family income
Questions Included
„ Population of community in which the child
resides
„ Number of siblings
„ Family status at birth
„ Family status currently
„ Education location and hours per week
„ Family history of speech/language delay
„ Health checklist
Health Checklist
„ Collected pediatric health questionnaires
from local doctors
„ Developed a list of 30 health problems
„ Parent indicates yes or no for each item
„ Examples of problems listed: meningitis,
frequent ear infections, jaundice,
ADD/ADHD
Ages and Stages Questionnaire
„ Squires, Potter, and Bricker (1999)
„ Purpose: to identify infants or young children who
are in need of further evaluation
„ 30 developmental items
„ 5 categories: communication, gross motor, fine
motor, problem solving, personal/social
„ 19 questionnaires total for 4 months-60 months
„ 5 questionnaires used for this study for ages 3-5
Child Behavior Checklist
„ Achenbach and Rescorla, 2001
„ One component of the Achenbach System of
Empirically Based Assessment (ASEBA)
„ 100 statements
„ For each statement, parent indicates:
„ Not true
„ Somewhat or sometimes true
„ Very true or often true
Child Behavior Checklist
„ To score, items are sorted into specific categories:
„ Emotionally Reactive
„ Anxious/Depressed
„ Somatic Complaints
„ Withdrawn
„ Sleep Problems
„ Attention Problems
„ Aggressive Behavior
„ Other Problems
„ Overall internal, external, and total scores also provided
Fluharty Preschool Speech and
Language Screening Test -2
„ Fluharty (2001)
„ Used in this study to classify children as at risk for
a speech/language delay
„ Subtests include:
„ Articulation
„ Repeating Sentences
„ Following Directives and Answering Questions
„ Describing Actions
„ Sequencing Events
Selection of Preschools
„ Focused on obtaining a representative
sample of responses (especially for
population, education location, and income)
„ 76 packets were mailed to preschools
across the state of Missouri
„ 20 preschools agreed to participate
„ 14 preschools were able to be scheduled
Missouri Map
Working with the Preschools
„ Scheduled date to screen the children
„ Obtained name and birthday information
„ Printed and hand signed individual letters for each
child
„ Stuffed packets with appropriate questionnaires
„ Printed and hand signed reminder flyers for each
child
„ Mailed packets and reminders to preschool to
distribute
On the Screening Days
„ Collected returned packets
„ Verified completion of consent forms and
questionnaire
„ Administered Fluharty-2 only to the children
whose parents completed the questionnaire
Following the Screenings
„ Scored the Fluharty-2 tests
„ Mailed letter to each preschool notifying them
which children passed and which children failed
„ Provided an individual letter to each parent of the
children who failed the screening
„ Provided information about recommended follow
up for those that failed the screening (to school
and parent)
Results
Data Collected
„ Over 600 questionnaires were sent home to
parents of preschoolers
„ Approximately 250 questionnaires were
completed and returned (Approx. 42% return
rate)
„ 210 preschoolers were administered the Fluharty-
2 (due to absence, non-compliance, etc.)
„ 152 questionnaires were complete and able to be
used
Father Involved vs. Father Not Involved
„ Questions were designed to be answered
even if the father was not in the child’s life
„ However, if the father was not involved,
most left all father questions blank
„ To analyze data, data points with all father
questions left blank were analyzed
separately
Father Involved
„ 71 females, 52 males
„ Average age was 4 years, 2 months
„ 83.7% Caucasian, 2.4% Hispanic
„ Average pregnancy length 38.7 weeks
„ Average age of mother at birth: 27 years
 Level of Father's Depression

90

Father Involved
80

70

60
Number

50

40

30

20

10

0
Rarely Occasionally Frequently Past Treatment Current Treatment
Severity of Depression
 Reported Family Income

35

30

25
Number

20

15

10

0
Under $19,999 $20,000- $40,000- $60,000- $80,000- $100,000- Over $300,000
$39,999 $59,999 $79,999 $99,999 $299,999
Income Bracket
 Education Location

60

50

40
Number

30

20

10

0
Public Preschool Private Preschool Public Daycare In Home Daycare Head Start
Type of Location
Father Involved
„ Children spent an average of 26 hours per
week in a preschool or daycare location
„ 22.8% reported a family history of
speech/language problems
„ 18.7% failed the Fine Motor section of the
ASQ
„ 3.25% failed the Problem Solving section of
the ASQ
Linear Regression
„ y is usually a continuous variable (Fluharty-2
score)
„ A variable is included in the model if it helps
explain some of the variation in the outcome
(Fluharty-2 score) that is not accounted for by the
other explanatory variables
„ Variable is included if p<.05, excluded if p>.05
„ Assumes all variables are normally distributed
Linear Regression
„ Forward regression: adds variables to the
model that have a p-value < .05
„ Backward regression: starts with all
variables in the model, removes those with
a p-value > .05
„ Stepwise regression: combines elements
of forward and backward regression
Linear Regression
„ Outcome = y = Fluharty-2 GLQ Score
„ Selected 35 of 80 variables
„ Adjusted R2 = .431
Linear Regression Model GLQ
Predicted
Actual Pass Fail % Correct
Pass 100 5 95.2%
Fail 11 7 38.9%
Overall 87.0%
Factors Increasing Child’s Risk
„ Failing ASQ Communication
„ Failing ASQ Problem Solving
„ Mother with no high school diploma or GED
„ Father with no high school diploma or GED
„ Single mother at birth
„ Divorced couple currently
„ Failing Child Behavior Checklist Internal Score
Factors Decreasing Child’s Risk
„ Higher birth weight
„ Private preschool education location
„ More hours in preschool/daycare per week
Logistic Regression
„ Logistic regression does not assume that each
variable is normally distributed
„ Used when outcome is binary (pass or fail)
„ Used when most variables are continuous as
opposed to discrete
„ We used many discrete variables that could not
be continuous, such as family status
„ Used to predict if child would pass or fail any
section of the Fluharty-2
Logistic Regression Model
Predicted
Actual Pass Fail % Correct
Pass 93 5 94.9%
Fail 6 22 78.6%
Overall 91.3%
Factors Increasing Child’s Risk
„ Hispanic
„ Older mother at birth
„ Father treated for depression
„ Low income ($20,000-$39,999)
„ Family history of speech/language delay
„ Failing ASQ Fine Motor
„ Failing ASQ Problem Solving
Factors Decreasing Child’s Risk
„ Older age of child
„ Longer pregnancy
„ Private preschool education location
„ More hours in preschool/daycare per week
Variables Not Selected
„ Behavior traits from the Child Behavior
Checklist
„ Attention
„ Aggression
„ Level of Parent Education
„ Population
Father Not Involved
„ 19 children
„ Logistic regression used
„ At risk factors:
„ Failing ASQ Communication section
„ Parents were separated at birth
Logistic Regression Model
Predicted
Actual Pass Fail % Correct
Pass 12 1 92.9%
Fail 1 4 80.0%
Overall 89.5%
So what can we do?
Collect Case Histories
„ Several important factors could be
identified from case history information
„ Mother’s age at birth
„ Pregnancy length
„ Family history of speech/language delay
Administer ASQ
„ Parents can complete in a very short time
„ Easy to score
„ Identify children that fail the Fine Motor or
Problem Solving sections
Variables You Can’t Change
„ Ethnicity
„ Father’s level of depression
„ Income
„ Family History
Prevention
„ Knowing these at risk factors, how can we
overcome them?
„ Educating parents and child care providers
„ Implement special program to address
these variables
„ Activities to improve problem solving abilities
„ Additional activities for children identified as at
risk
Push-In Activities
„ SLPs could develop push-in activities to
work with all students
„ Provides at risk students with early speech-
language intervention
„ Could help decrease the number of
students that require services later
What would we have done
differently?
Questionnaire Adjustments
„ Pilot the questionnaire with parents prior to beginning the study
„ Separate questionnaires for father involved in the child’s life and
father not involved
„ Use more continuous variables
„ Ex) Instead of bracketing income, allow families to provide a specific
number.
„ Logistic regression would be even more appropriate if more
variables were continuous
Questionnaire Adjustments
„ Further stress the importance of answering
EVERY question
„ Use a more formal measure of level of depression
„ Unclear how to answer some questions if a step-
parent was in the child’s life
Preschool Selections
„ Spend more time traveling to different
preschools
„ Send out more packets in order to have
more preschools in larger cities
„ Contact SLPs at the school districts in
order to have a better liaison
Ideas for Future Research
Future Research
„ Make modifications to data collection process
„ Adjust questionnaire
„ Contact more preschools to collect more data
„ Compare linear vs. logistic regression analysis
„ Explore specific questions on the ASQ to
determine if individual questions are predictive
Future Research
„ With current model or new model:
„ Explore ways preschools can use this information to help
PREVENT speech/language delays
„ Conduct an experiment by implementing a program at
some preschools and not others, compare
speech/language skills pre- and post-implementation
„ Ex) Preschool teachers implement structured problem
solving activities
„ Ex) At risk students receive special programming one a
week
Future Research
„ Explore ways parents can use this
information to help an at risk child
„ Would certain activities conducted by the parents
decrease the child’s at risk status?
„ Certain variables cannot be easily changed (such
as income and level of parent education), but
can the parents help the child overcome these at
risk factors?
Questions?
References
„ Achenbach, T.M. & Rescorla, L.A. (2001). Child Behavior Checklist. Burlington: Research
Center for Children, Youth, & Families.
„ Bricker, D. & Squires, J. (1999). Ages and Stages Questionnaires: A parent-completed, child-
monitoring system. (2nd ed.). Baltimore: Paul H. Brookes.
„ Dale, P.S., Price, T.S., Bishop, D.V.M., & Plomin, R. (2003). Outcomes of early language delay:
I. Predicting persistent and transient delay at 3 and 4 years. Journal of Speech,
Language and Hearing Research, 46, 544-560.
„ Fluharty, N.B. (2001). Fluharty Preschool Speech and Language Screening Test. (2nd Ed.).
Austin: ProEd.
„ La Paro, K.M., Justice, L., Skibbe, L.E., & Pianta, R.C. (2004). Relations among maternal, child,
and demographic factors and the persistence of preschool language impairment.
American Journal of Speech-Language Pathology, 13, 291-303.
„ Tomblin, J.B., Smith, E., & Zhang, X. (1997). Epidemiology of specific language impairment:
Prenatal and perinatal risk factors. Journal of Communication Disorders, 30, 325-344.
„ Zubrick, S.R., Taylor, C.L., Rice, M.L., & Slegers, D.W. (2007). Late Language Emergence at
24 Months: An Epidemiological Study of Prevalence, Predictors, and Covariates.
Journal of Speech, Language, and Hearing Research, 50, 1562-1592.