Received: 4 April 2023 Accepted: 28 August 2023

DOI: 10.1111/1460-6984.12950

RESEARCH REPORT

Do parent-reported early indicators predict later

developmental language disorder? A Raine Study
investigation
Samuel D. Calder1 Mark Boyes2,3 Christopher G. Brennan-Jones4,5
Andrew J. O. Whitehouse4 Monique Robinson4 Elizabeth Hill3,5
1 Health Sciences, College of Health and Medicine, University of Tasmania, Launceston, TAS, Australia
2 Curtin School of Population Health, Faculty of Health Sciences, Curtin University, Perth, WA, Australia
3 enAble Institute, Curtin University, Perth, WA, Australia
4 Telethon Kids Institute, The University of Western Australia, Perth, WA, Australia
5 School of Allied Health, Faculty of Health Sciences, Curtin University, Perth, Australia

Correspondence
Samuel D. Calder, Health Sciences,
College of Health and Medicine,
University of Tasmania, Private Bag 19,
Nipaluna/Hobart, TAS 7001, Australia.
Email: samuel.calder@utas.edu.au
Funding information
We thank the NHMRC for their long-term
contribution to funding the study over the
last 30 years. The core management of the
Raine Study is funded by The University
of Western Australia, Curtin University,
Telethon Kids Institute, Women and
Infants Research Foundation, Edith
Cowan University, Murdoch University,
The University of Notre Dame Australia,
and the Raine Medical Research
Foundation. Mark Boyes is supported by
the National Health and Medical
Research Council, Australia (investigator
grant number 1173043). Christopher G.
Brennan-Jones is supported by a WA
Department of Health FHRIF Emerging
Leader Fellowship.
Abstract
Background: Developmental language disorder (DLD) is one of the most com-
mon neurodevelopmental conditions. Due to variable rates of language growth in
children under 5 years, the early identification of children with DLD is challeng-
ing. Early indicators are often outlined by speech pathology regulatory bodies
and other developmental services as evidence to empower caregivers in the early
identification of DLD.
Aims: To test the predictive relationship between parent-reported early indica-
tors and the likelihood of children meeting diagnostic criteria for DLD at 10 years
of age as determined by standardized assessment measures in a population-based
sample.
Methods: Data were leveraged from the prospective Raine Study (n = 1626
second-generation children: n = 104 with DLD; n = 1522 without DLD). These
data were transformed into 11 predictor variables that reflect well-established
early indicators of DLD from birth to 3 years, including if the child does not
smile or interact with others, does not babble, makes only a few sounds, does
not understand what others say, says only a few words, says words that are not
easily understood, and does not combine words or put words together to make
sentences. Family history (mother and father) of speech and language difficulties
were also included as variables. Regression analyses were planned to explore the
predictive relationship between this set of early indicator variables and likelihood
of meeting DLD diagnostic criteria at 10 years.

This is an open access article under the terms of the Creative Commons Attribution-NonCommercial-NoDerivs License, which permits use and distribution in any medium,
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© 2023 The Authors. International Journal of Language & Communication Disorders published by John Wiley & Sons Ltd on behalf of Royal College of Speech and Language
Therapists.

Int J Lang Commun Disord. 2023;1–17. wileyonlinelibrary.com/journal/jlcd 1

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2 DO PARENT-REPORTED EARLY INDICATORS PREDICT LATER DEVELOPMENTAL LANGUAGE DISORDER?

Results: No single parent-reported indicator uniquely accounted for a signif-

icant proportion of children with DLD at 10 years of age. Further analyses,
including bivariate analyses testing the predictive power of a cumulative risk
index of combined predictors (odds ratio (OR) = 0.95, confidence interval (CI) =
0.85–1.09, p = 0.447) and the moderating effect of sex (OR = 0.89, CI = 0.59–1.32,
p = 0.563) were also non-significant.
Conclusions: Parent reports of early indicators of DLD are well-intentioned and
widely used. However, data from the Raine Study cohort suggest potential retro-
spective reporting bias in previous studies. We note that missing data for some
indicators may have influenced the results. Implications for the impact of using
early indicators as evidence to inform early identification of DLD are discussed.

KEYWORDS
developmental language disorder, early identification, the Raine study

WHAT THIS PAPER ADDS

What is already known on the subject
∙ DLD is a relatively common childhood condition; however, children with DLD
are under-identified and under-served. Individual variability in early child-
hood makes identification of children at risk of DLD challenging. A range
of ‘red flags’ in communication development are promoted through speech
pathology regulatory bodies and developmental services to assist parents to
identify if their child should access services.

What this paper adds to the existing knowledge

∙ No one parent-reported early indicator, family history or a cumulation of indi-
cators predicted DLD at 10 years in the Raine study. Sex (specifically, being
male) did not moderate an increased risk of DLD at 10 years in the Raine study.
Previous studies reporting on clinical samples may be at risk of retrospective
reporting bias.

What are the potential or actual clinical implications of this work?

∙ The broad dissemination and use of ‘red flags’ is well-intentioned; however,
demonstrating ‘red flags’ alone may not reliably identify those who are at later
risk of DLD. Findings from the literature suggest that parent concern may be
complemented with assessment of linguistic behaviours to increase the likeli-
hood of identifying those who at risk of DLD. Approaches to identification and
assessment should be considered alongside evaluation of functional impact to
inform participation-based interventions.

INTRODUCTION 10 years (Calder et al., 2022; Norbury et al., 2016; Tomblin

Developmental language disorder (DLD) is one of the most
common neurodevelopmental disorders. Prevalence esti-
mates indicate DLD affects roughly 7% of the population
in English-speaking countries between the ages of 5 and
et al., 1997, 2003). This rate of occurrence is greater than
other well-known neurodevelopmental disorders, such as
autism spectrum disorder, attention deficit/hyperactivity
disorder, intellectual disability and dyslexia (McGregor,
2020). Although the recency of widespread international

CALDER et al.
advocacy efforts to raise awareness of DLD is promising for
increased support of those affected the condition, children
with DLD have historically been under-identified for such
support (e.g., Skeat et al., 2010; Zhang & Tomblin, 2000).
The under-identification of children with DLD poses
a risk to public health, economic viability and individ-
ual well-being, with the long-term impacts of language
disorder to educational, vocational and societal outcomes
well documented. In a UK follow-up study of 17 men in
their 30s with a history severe receptive DLD in childhood,
Clegg et al. (2005) found a history of DLD was associated
with an increased risk of psychiatric disorder and social
adaptation difficulties, including academic outcomes and
educational provision, employment, independent living,
relationships, family life, and receipt of state benefits and
housing. Also in the UK, Conti-Ramsden et al. (2018) found
that in a study of 84 twenty-four-year-olds with a history of
DLD and 88 age-matched controls, those with DLD were at
increased risk of obtaining lower academic and vocational
qualifications despite few differences between groups
engaging with educational opportunities in adulthood.
Whitehouse et al. (2009a, 2009b) followed up adults who
had participated in previous studies of children and found
language and literacy difficulties persisted into adulthood
(early 20s) where a history of language disorder was associ-
ated with pursuing vocational training for professions that
do not require high levels of language and literacy pro-
ficiency. Whitehouse et al. also stressed the high level of
within-group variation which encourages individualized
evaluations of those living with language disorder. In a
Canadian longitudinal study of 142 individuals with DLD
and 142 controls followed up at 5, 12 and 19 years, males
with a history of language disorder were four times more
likely to engage in delinquent and aggressive behaviour
compared to controls (Brownlie et al., 2004), and females
with a history of DLD were three times more likely to expe-
rience sexual assault when compared to controls (Brownlie
et al., 2007). From an economic standpoint, the cost to soci-
ety of language disorders in Australia is estimated to be
between A$1.362 billion and A$3.308 billion per year, with
most of the burden attributed to productivity losses of car-
ing for children with language difficulties (Cronin, 2017).
There are alarming patterns of inequity to service access
for children with DLD. Although there does not appear
to be a significant difference in the sex distribution of
children with DLD in population-based studies (Calder
et al., 2022; Norbury et al., 2016; Tomblin et al., 1997),
Whitehouse (2010) conducted a meta-analysis of sex ratio
differences in family aggregation studies of DLD (then
referred to as specific language impairment—SLI), and
found that more males than females were identified
to have DLD via direct assessment methods; however,
there were no sex differences observed through indirect
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3
assessment of language. There also appears to be a refer-
ral bias favouring males in receipt of clinical services for
language difficulties. Lindsay and Strand (2016) found that
males with language disorder are more than twice as likely
to be referred for clinical services in the UK, and Morgan
et al. (2017) found males are almost twice as likely to be
referred in the United States. The reasons for the dispari-
ties in service access between males and females is unclear;
however, there is some evidence to suggest that language
difficulties in young children are more likely to resolve in
females than males (Dale et al., 2003), and males demon-
strate more externalized behaviours compared to females,
who may be more prone to internalize difficulties (Toseeb
et al., 2017).
Early identification of DLD is critical to alleviate
the potential socio-emotional and economic burden
of language difficulties and maximizes the benefits of
intervention (Fan et al., 2022). An investigation of the Lon-
gitudinal Study of Australian Children identified child,
parent and family factors may influence language develop-
ment (Harrison & McLeod, 2010). The same study reported
risk factors for speech and language impairment in 4–5-
year-old children including being male, having ongoing
hearing problems, having a more reactive temperament,
having an older sibling, parents speaking a language other
than English, and support for the child’s learning at home.
Rudolph (2017) conducted a review of epidemiological
studies and found 11 case history risk factors for DLD (then
SLI), specifically, which included a range of biological, pre-
natal, perinatal, and family history factors. Once analysed
for clinical significance, however, the odds of developing
DLD among children whose mothers has low maternal
education, who had a low 5-min APGAR score, were born
later or male was as high as the odds as late talking pre-
dicting DLD. Prospective cohort studies published since
Rudolph’s review have identified perinatal and/or envi-
ronmental risk factors for low language ability beyond the
preschool years. These include parental education (Chris-
tensen et al., 2014; Reilly et al., 2018), socio-economic
disadvantage (Christensen et al., 2014), non-English
speaking background (Reilly et al., 2018), family history
of speech/language difficulties (Christensen et al., 2014;
Reilly et al., 2018), and mothers smoking while pregnant
(Armstrong et al., 2017; Calder et al., 2022). Notably, most
of these epidemiological studies do not find differences
between males and females with language difficulties,
suggesting being a male may not be identified as a risk fac-
tor in unselected samples (cf. Rudolph, 2017; Whitehouse,
2010).
Certainly, there is a need for recognizing the biological,
perinatal and environmental risk factors associated with
DLD services to identify vulnerable individuals who may
be prioritized for clinical services. However, these factors

4 DO PARENT-REPORTED EARLY INDICATORS PREDICT LATER DEVELOPMENTAL LANGUAGE DISORDER?
alone cannot be leveraged to identify children with, or at
risk of, language disorder. Direct assessment of language
development in the early years is necessary. Yet, predicting
the trajectory of language development is complex. In the
large-scale Twins Early Development Study in the UK,
Dale et al. (2003) found that 44.1% of children who were
identified to have language delay at 2 years of age has
persistent language difficulties at 3 years, and 40.2% had
persistent difficulties at 4 years. In a subsequent analysis,
Bishop et al. (2003) reported that parental concern at 3
years and accessing professional support at 4 years was
associated with greater heritability of language difficulties,
whereas language delay at 2 years appeared to be associ-
ated with environmental influences when parents do not
express concern or access professional support. The Early
Language in Victoria Study has taken a programmatic
approach to tracking the development of language in an
Australian population sample. Findings from this longi-
tudinal study indicated at 2 years, 19% of the sample were
classified at late talkers; however, 14% (73.7% of late talkers
at 2 years) spontaneously caught up to their peers at
4 years, while the remaining 5% of late talkers plus 6% of
the typical talkers (7.4% at 2 years) went on to have low lan-
guage at 4 years, totalling 11% of the entire sample (Reilly
et al., 2018). These findings emphasize the complexity and
individual variability of language development in early
childhood, and stress that late talking is not necessarily a
reliable indicator of later language difficulties.
Recent literature has highlighted approaches to address-
ing the nuances of early identification of language dif-
ficulties. A scoping review of 37 studies evaluated early
predictors, age for diagnosis and diagnostic tools to
inform evidence-based practice in the assessment of DLD
(Sansavini et al., 2021). Delays in gesture production, low
receptive and/or expressive vocabulary, and limited word
combinations up to 30 months were found to be early
indicators of later DLD. Family history of language difficul-
ties was a significant risk factor while low socio-economic
status and communication environments were risk fac-
tors with lower predictive power. Recommendations from
the review included screening for language ability at 2–3
years and applying a diagnosis if relevant at 4 years using
standardized tests and psycholinguistic measures assess-
ing morpheme use and mean length of utterances. Another
recent study harmonized variables from two datasets
(Early Identification of Risk for Language Impairment and
Language Acquisition and Semantic Relations) (Borovsky
et al., 2021). Variables included demographic and linguis-
tics measures from the MacArthur Bates Communica-
tive Development Inventory. Machine learning techniques
identified grammatical and lexico-semantic markers as
predictive of language delay in the early years, with
demographic variables having lower predictive power.
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Such complex analyses reveal the nuanced nature of
language development and the difficulty associated with
early identification of children at risk of DLD. Thankfully,
previous authors have elucidated ‘red flags’ by com-
bining findings from previous literature. Unsurprisingly,
communicating in shorter sentences, difficulty with rule
formation around sounds, words, and sentences, as well
as poorly developed social use of language and overall
vocabulary as red flags for DLD (Prelock et al., 2008).
In the international CATALISE study for consensus on
identifying DLD, Bishop et al. (2016) outlined the follow-
ing consensus statements relating to early identification of
children at-risk of DLD:
∙ Between 1 and 2 years of age, the following features are
indicative of atypical development in speech, language
or communication: (a) no babbling; (b) not responding
to speech and/or sounds; and (c) minimal or no attempts
to communicate (p. 9).
∙ Between 2 and 3 years of age, any of the following fea-
tures is indicative of atypical development in speech,
language or communication: (a) minimal interaction;
(b) does not display intention to communicate; (c)
no words; (d) minimal reaction to spoken language;
and (e) regression or stalling of language development
(p. 10).
∙ Between 3 and 4 years of age, any of the following fea-
tures is indicative of atypical development in speech,
language or communication: (a) at most two-word utter-
ances; (b) child does not understand simple commands;
and (c) close relatives cannot understand much of child’s
speech. (p. 10).
∙ Children’s language can change dramatically, especially
in the preschool/early school years (aged 4–5 years),
even if there is no intervention. However, severe lan-
guage impairment involving both comprehension and
expression is more likely to be persistent (p. 10).
The final statement reiterates the individual variabil-
ity in the acquisition of early communication mile-
stones/displaying red flags for later language disorder. The
individual differences in language appear to become more
stable after the onset of formal schooling, although, this
also means that the rate of language learning remains sta-
ble (Norbury, 2019). Therefore, if children begin school
below their peers in terms of their language skills, they may
not be able to develop their language learning at a rate that
catches up to those with average language. The stability
in the rate of language growth after the onset of school-
ing persists despite variation in child, parent and family
factors (Norbury, 2019). That is, child, parent and family
factors may not fully explain individual differences in lan-
guage ability: some children are born with low language

CALDER et al.
abilities despite good caregiver–child interactions in the
early years. The challenge is to reliably identify these chil-
dren to provide services to ameliorate communication and
functional outcomes as soon as possible.
Improved identification of DLD in the early years may
serve to mitigate the persistent and pervasive impacts
from childhood into adulthood. In efforts to inform
the wider public, online developmental resources (e.g.,
UpToDate, 2023), including speech pathology regulatory
bodies publish early language milestones (e.g., American
Speech & Hearing Association, n.d.; Royal College of
Speech–Language Therapists, n.d.; Speech Pathology
Australia, n.d.), which may note red flags. These useful
and freely available resources can empower caregivers
to identify whether their child may be at risk of DLD.
Interestingly, when one follows these links, empirical
evidence to support these red flags is typically implied,
suggesting that failure to meet milestones is indeed the
red flag. Non-for-profit organizations also provide easily
accessible information for the public (e.g., Boys Town
Hospital, 2021; The Hanen Centre, n.d.). Again, evidence
of empirical support on these pages is implied. Finally,
private organizations provide publicly available informa-
tion in efforts to empower caregivers to make referrals
when appropriate (e.g., Banter Speech, n.d.; Lee Slew, n.d.;
North Shore Pediatric Speech Therapy, n.d.). These again
usually highlight communication milestones and failure
to meet them as red flags for later language disorder.
Although these resources serve as valuable information
to the wider public, it is not clear that the use of these red
flags to identify children at risk of DLD is empirically sup-
ported. Large, unselected samples from population-based
studies allow for investigation of prevalence of conditions,
as well as the evaluation of relationships between disorders
and exposures, such as the potential risk factors described
above.
The Raine Study
The Raine Study is longitudinal cohort study that enrolled
roughly 2900 pregnant women in Western Australia
(Newnham et al., 1993). Between 1989 and 1992, 2730 moth-
ers (Gen1) gave birth to 2868 offspring (Gen2) (Dontje et al.,
2019), and the offspring of Gen2 are currently being fol-
lowed up. Mothers and children of the Raine Study have
found to be representative of the general population at
study follow-ups (see Dontje et al., 2019; Straker et al.,
2017; White et al., 2017 for summaries). The rich datasets
available within the Raine Study have been studied to esti-
mate the prevalence of many childhood conditions, such
as otitis media and hearing loss (Brennan-Jones et al.,
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5
2020a), attention deficit hyperactivity disorder (Middle-
dorp et al., 2016), and conduct and behavioural disorders
(Ayano et al., 2021). Studies have also used Raine study data
to evaluate the relationships between childhood language
abilities and other conditions and/or exposures, such as
otitis media (Brennan-Jones et al., 2020b), maternal stress
(Whitehouse, 2010), testosterone (Whitehouse et al., 2012)
and anaesthesia (Ing et al., 2012).
Recently, the prevalence of and potential perinatal and
environmental risk factors for DLD at 10 years were esti-
mated in the Raine Study (Calder et al., 2022). Participants
included 1626 children with available language data. Preva-
lence of DLD was indicated by scores on standardized
measures of language (Clinical Evaluation of Language
Fundamentals—3 (CELF-3); Semel et al., 1995) and non-
verbal intelligence (Raven’s Coloured Progressive Matrices
(RCPM); Raven, 1977). Of the total sample, n = 104 cases
scored 1.50 SD (standard deviations) or below the popu-
lation mean on the CELF-3 and within −2.00 SD on the
RCPM, suggesting a prevalence rate of 6.4%, which is sim-
ilar to prevalence estimates in younger children in other
English-speaking countries (Norbury et al., 2016; Tomblin
et al., 1997). Notably, only two cases that met criteria for
DLD based on standardized assessment were identified to
have a language disorder by a health professional at the
10-year follow-up. This highlights a potential discrepancy
between children who are likely to meet criteria for DLD
based on test performance and those who accessed services
for clinically significant language difficulties.
The strongest predictor for later DLD at 10 years was
children who were exposed to tobacco smoke in utero at
18 weeks. Again, this finding was similar to Tomblin et al.
(1998) who found smoking during and after pregnancy
was associated with language disorder at 6 years. How-
ever, Tomblin et al. found that once parental education was
controlled for, the association was washed out, leading the
authors to conclude that smoking is more likely a deter-
minant of disadvantaged parenting environment than a
causal risk factor for language disorder. Indeed, Calder
et al. (2022) highlighted that there was a significantly
higher proportion of families who had household incomes
< A$27,000 per year who did not provide language data,
which made it difficult to rule out social determinants of
DLD at 10 years. Another limitation noted in this study was
that two important criteria for determining DLD diagno-
sis could not be obtained from the Raine Study dataset: (1)
early onset of language difficulties; and (2) the functional
impact of the condition. While the current study attempts
to elucidate the limitation of not addressing the first cri-
terion, the measurement of functional impact presents a
persisting challenge to epidemiological research in this
space (see Calder et al., 2023 for a discussion).

6 DO PARENT-REPORTED EARLY INDICATORS PREDICT LATER DEVELOPMENTAL LANGUAGE DISORDER?
The current study
The aim of this study was to inform the predictive power of
early signs of DLD in an unselected and representative lon-
gitudinal Australian birth cohort (Raine Study) at 10 years.
Our objectives were as follows:
∙ To leverage Raine Study data to create variables repre-
senting clinically relevant parent-reported early indica-
tors of DLD.
∙ To test associations between parent-reported indicators
and children meeting diagnostic criteria for DLD at
10 years.
A systematic analysis of the predictive power of parent-
reported early indicators of DLD will inform the utility in
using such indicators for the early identification of this at-
risk population.
METHODS
Participants
This study included variables from n = 1626 live births
at King Edward Memorial Hospital in Perth, Western
Australia, between 1989 and 1991. Data were analysed
from 1-year (1990−93), 2-year (1991−94), 3-year (1992−95)
and 10-year (1999−2002) follow-ups. Each follow-up was
approved by the institutional ethics committee and written
informed consent from the participants was obtained for
each follow-up. Recruitment and follow-up for the Raine
Study were approved by the Human Ethics Committee
at King Edward Memorial Hospital. Analysis of existing
data was approved by the Raine Study and Curtin Human
Research Ethics Committee (HREC approval number
HRE2021-0117). Demographic information and the fre-
quencies of children with (n = 104) and without (n = 1522)
DLD are presented in Table 1, which is rereported from
Calder et al. (2022, tab. 2, p. 2047).
Variables
The primary outcome variable for this study was children
meeting diagnostic criteria for DLD at 10 years. Partici-
pants were classified at meeting criteria for DLD if z-scores
on the CELF-3 Total Language Score was at or below
1.50 the population sample mean and z-scores on the
RCPM were ≥ −2.00 within the sample population mean.
Z-scores were used to determine the thresholds for diag-
nostic criteria primarily since the CELF-3 was not normed
on an Australian population; and second, to align with
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previous population-based studies which used SD cut-offs
to determine prevalence estimates. Specifically, a thresh-
old of −1.50 SD below the population mean on a language
composite and within −2.00 SD on a measure of non-
verbal intelligence was applied by Norbury et al. (2016),
and a cut-off of −1.25 SD below the mean on a language
composite and within −1.00 SD on a measure of non-
verbal intelligence was applied by Tomblin et al. (1997).
We chose to apply the thresholds applied by Norbury
et al. (2016) in keeping with the most recent prevalence
estimate that corresponds to updates to diagnostic ter-
minology of DLD (Bishop et al., 2017) and international
classification systems such as the Diagnostic and Sta-
tistical Manual—5 (American Psychological Association
(APA), 2013) and International Classification of Diseases—
11 (ICD-11) (World Health Organization (WHO), 2019).
Sensitivity and specificity values of the z-score thresholds
were determined using receiver operating characteristic
curves and are reported in Supplemental Material 1, indi-
cating at or above acceptable discrimination on all metrics
(Hosmer & Lemeshow, 2000). All cases that met z-score
thresholds for DLD were individually checked for ICD
codes (parent report) for other biomedical conditions (e.g.,
autism, intellectual disability, hearing loss) that may better
explain language difficulties. Of the total sample of 1626, n
= 16 cases were considered to have language disorder asso-
ciated with intellectual disability as indicated non-verbal
intelligence more than −2.00 SD below the population
mean (i.e., no corresponding ICD code provided). No cases
from the no-DLD group were excluded based on an ICD
code or parent report of a biomedical condition to maintain
the representativeness of the population sample.
Early parent-reported indicator variables were selected
based on their alignment with existing research literature,
early milestones, and communication red flags that are
frequently reported through public and/or speech pathol-
ogy advocacy forums outlined earlier and their availability
within the Raine Study repository. A total of 11 parent-
reported early indicators of DLD were leveraged into
dichotomous variables from parent questionnaires at 1-, 2-
and 3-year follow ups. At the 1-year follow-up, concern on
parent-reported early indicators included a ‘no’ response
to the following: (1) smiling at or before 6 weeks old, (2)
babbling at or before 6 months old, (3) first words at or
before 12 months old, (4) following one simple command at
12 months old and (5) pointing or looking at objects when
asked. At the 2-year follow-up, concern on parent-reported
indicators included a ‘no’ response to the following: (6)
speech clear at or more than 50% of the time, (7) combining
words and (8) speaking in sentences. At the 3-year follow-
up, concern on parent-reported early indicators included
a ‘no’ response to the following: (9) speech clear at or
more than 50% of the time, (10) speaking in sentences and
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CALDER et al. 7

TA B L E 1 Demographic information and frequencies of children with and without developmental language disorder in the Raine Study
DLD, n (%) No DLD, n (%)
Total number 104 (6.4%) 1506 (92.6%)
16 (1.0%)a
Socio-economic status
< A$27 000 56 (53.8%) 835 (54.9%)
≥ A$27 000 40 (38.5%) 604 (39.7%)
Not stated 8 (7.7%) 83 (5.4%)
Ethnicity
Caucasian 95 (91.4%) 1345 (88.4%)
Aboriginal 2 (1.9%) 29 (1.9%)
Polynesian 2 (1.9%) 13 (0.8%)
Vietnamese 0 7 (0.5%)
Chinese 2 (1.9%) 68 (4.5%)
Indian 3 (2.9%) 41 (2.7%)
Other 0 19 (1.2%)
Language spoken most at home
English 101 (97.1%) 1439 (94.5%)
Vietnamese 0 10 (0.7%)
Chinese 0 18 (1.2%)
Italian 0 1 (0.1%)
Greek 0 3 (0.2%)
Spanish 0 5 (0.3%)
Other 3 (2.9%) 46 (3.0%)
Note: Language disorder associated with intellectual disability, that is, NVIQ ≥ 2.0 SD below the mean.

(11) combining sentences. Positive family history of speech
and/or language difficulties from either the (12) mother or
(13) father were also leveraged as predictor variables. See
Supplemental Material 2 for a visual synthesis of how com-
munication milestones, red flags and risk factors in the
research literatures map on to clinically relevant parent-
reported early indicators. Specific wording of questions
in relation to the transformed variables are presented in
Supplemental Material 3.
Statistical analysis
Frequency distributions of parent-reported early indica-
tors and family history of speech and/or language diffi-
culties were analysed with χ2 -tests based on whether or
not children met diagnostic criteria for DLD at 10 years.
We also converted the parent-reported early indicators into
a cumulative risk index by summing ‘no’ responses (i.e.,
concern) across each dichotomous variable across 1–3-year
follow-ups into a continuous variable to determine if such
a variable would generate a profile that predicted later
DLD. That is, do multiple independent parent-reported
indicators predict DLD at 10 years? Bivariate analyses were
planned to evaluate the moderating effect of sex on DLD
as a predictive outcome. Data were analysed using SPSS
version 28.
RESULTS
Frequency distributions of parent-reported early indica-
tors from birth to 3-year follow-ups and family history of
speech and/or language difficulties are reported in Table 2.
The only significant difference in the proportion of chil-
dren with or without DLD and responding ‘no’ to early
indicators on any parent-reported variables was babbling
at or earlier than 6 months, where fewer females with
DLD at 10 years were reported to have concerns by their
parents than females without DLD. We note here, that
descriptively, some indicators represented roughly equiv-
alent proportions of concern across both groups, including
smiling ≤ 6 weeks (no DLD = 22.0%; DLD = 21.7%), point-
ing/looking at objects when asked ≤ 12 months (no DLD =
15.0%; DLD = 16.5%), and speaking in sentences at 2 years
(no DLD = 20.4%; DLD = 21.3%). We also note that the
proportion of concern appeared to decrease across 1–3-year
follow-ups, with 21.7–51.8% of concern for all indicators
 8

TA B L E 2 Frequency distributions and results of χ2 tests of parent-reported early indicators from birth to 3-year follow-ups and family history of speech and/or language difficulties
Parent-reported early
indicators No concern Concern (%) Total Missing cases χ2 -statistic p-value
Smile ≤ 6 weeks Male No DLD 476 136 (22.2%) 612 158 0.119 0.730
DLD 34 11 (24.4%) 45 10
Total 510 147 (22.4%) 657 168
Female No DLD 446 124 (21.8%) 570 182 0.234 0.628
DLD 31 7 (18.4%) 38 11
Total 477 131 (21.5) 608 193
Total No DLD 922 260 (22.0%) 1182 338 0.004 0.947
DLD 65 18 (21.7%) 83 21
Babble ≤ 6 months Male No DLD 259 283 (52.2%) 542 228 0.176 0.674
DLD 19 18 (48.6%) 37 18
Total 278 301 (51.9%) 579 246
Female No DLD 267 243 (47.6%) 510 242 5.173 0.023a
DLD 24 9 (27.3%) 33 16
Total 291 252 (46.4%) 543 258
Total No DLD 526 526 (50.0%) 1052 468 3.430 0.064
DLD 43 27 (38.6%) 70 34
First word ≤ 12 months Male No DLD 326 298 (47.7%) 624 146 3.516 0.061
DLD 17 28 (62.2%) 45 10
Total 343 326 (48.7%) 669 156
Female No DLD 347 233 (40.2%) 580 172 0.007 0.932
DLD 23 15 (39.5%) 38 11
Total 370 248 (40.1%) 618 183
Total No DLD 673 531 (44.1%) 1204 316 1.865 0.172
DLD 40 43 (51.8%) 83 21
Follows one simple Male No DLD 601 41 (6.3%) 642 128 0.374 0.541
command ≤ 12 months
DLD 42 4 (8.7%) 46 9
Total 643 45 (6.5%) 688 137
Female No DLD 593 24 (3.9%) 617 135 0.176 0.675
DLD 38 1 (2.6%) 39 10
Total 631 25 (3.8%) 656 145
Total No DLD 1194 65 (2.8%) 1259 261 0.083 0.773
DLD 80 5 (5.9%) 85 19
(Continues)
DO PARENT-REPORTED EARLY INDICATORS PREDICT LATER DEVELOPMENTAL LANGUAGE DISORDER?

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 CALDER et al.

TA B L E 2 (Continued)
Parent-reported early
indicators No concern Concern (%) Total Missing cases χ2 -statistic p-value
Pointing/looking at objects Male No DLD 527 108 (17%) 635 135 0.197 0.657
when asked ≤ 12 months
DLD 37 9 (19.6%) 46 9
Total 564 117 (17.2%) 681 144
Female No DLD 535 79 (12.9%) 614 138 0.000 0.993
DLD 34 5 (12.8%) 39 10
Total 569 84 (12.9%) 653 148 0.140 0.709
Total No DLD 1062 187 (15%) 1249 271
DLD 71 14 (16.5%) 85 19
Speech clear ≥ 50% of the Male No DLD 372 45 (10.8%) 417 353 0.006 0.940
time at 2 years
DLD 26 3 (10.3%) 29 26
Total 398 48 (10.8%) 446 379
Female No DLD 357 12 (3.3%) 369 383 0.772 0.380
DLD 23 0 (0.0%) 23 26
Total 380 12 (3.1%) 392 409
Total No DLD 729 57 (7.3%) 786 734 0.161 0.688
DLD 49 3 (5.8%) 52 52
Combines words at 2 years Male No DLD 450 58 (11.4%) 508 262 2.243 0.134
DLD 32 1 (3.0%) 33 22
Total 482 59 (10.9%) 541 284
Female No DLD 443 18 (3.3%) 461 291 1.256 0.262
DLD 31 0 (0.0%) 31 18
Total 474 18 (3.7%) 492 309
Total No DLD 893 76 (7.8%) 969 551 3.433 0.064
DLD 63 1 (1.6%) 64 40
(Continues)
9

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 10

TA B L E 2 (Continued)
Parent-reported early
indicators No concern Concern (%) Total Missing cases χ2 -statistic p-value
Speaks in sentences at Male No DLD 365 138 (27.4%) 503 267 0.000 0.984
2 years
DLD 24 9 (27.3%) 33 22
Total 389 147 (27.4%) 536 289
Female No DLD 392 56 (12.5%) 448 304 0.076 0.782
DLD 24 4 (14.3%) 28 21
Total 416 60 (12.6%) 476 325
Total No DLD 757 194 (20.4%) 951 569 0.029 0.864
DLD 48 13 (21.3%) 61 43
Speech clear ≥ 50% of the Male No DLD 565 24 (4.1%) 589 181 0.269 0.604
time at 3 years
DLD 40 1 (2.4%) 41 14
Total 605 25 (4.0%) 630 195
Female No DLD 553 9 (1.6%) 562 190 0.602 0.438
DLD 37 0 (0.0%) 37 12
Total 590 9 (1.5%) 599 202
Total No DLD 1118 33 (2.9%) 1151 369 0.682 0.409
DLD 77 1 (1.3%) 78 26
Speaks in sentences at Male No DLD 549 11 (2.0%) 560 210 0.800 0.371
3 years
DLD 40 0 (0.0%) 40 15
Total 589 11 (1.8%) 600 225
Female No DLD 519 6 (1.1%) 525 227 0.416 0.519
DLD 36 0 (0%) 36 13
Total 555 6 (1.1%) 561 240
Total No DLD 1068 17 (1.6%) 1085 435 1.208 0.272
DLD 76 0 (0.0%) 76 28
(Continues)
DO PARENT-REPORTED EARLY INDICATORS PREDICT LATER DEVELOPMENTAL LANGUAGE DISORDER?

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 TA B L E 2 (Continued)
CALDER et al.

Parent-reported early
indicators No concern Concern (%) Total Missing cases χ2 -statistic p-value
Combines sentences at Male No DLD 570 12 (2.1%) 582 188 0.045 0.832
3 years
DLD 38 1 (2.6%) 39 16
Total 608 13 (2.1%) 621 204
Female No DLD 540 7 (1.3%) 547 205 0.466 0.495
DLD 36 0 (0.0%) 36 13
Total 576 7 (1.2%) 583 218
Total No DLD 1110 19 (1.7%) 1129 391 0.053 0.819
DLD 74 1 (1.3%) 75 29
Maternal history of speech Male No DLD 483 31 (6.0%) 514 256 0.013 0.908
and/or language
problems
DLD 34 2 (5.6%) 36 19
Total 517 33 (6.0%) 550 275
Female No DLD 449 20 (4.3%) 469 293 1.244 0.265
DLD 28 0 (0.0%) 28 21
Total 477 20 (4.3%) 497 314
Total No DLD 932 51 (5.2%) 983 537 0.532 0.466
DLD 62 2 (3.1%) 64 40
Paternal history of speech Male No DLD 381 42 (9.9%) 423 347 1.419 0.234
and/or language
problems
DLD 29 1 (3.3%) 30 25
Total 410 43 (9.5%) 453 372
Female No DLD 359 22 (5.8%) 381 371 0.170 0.680
DLD 25 1 (3.8%) 26 23
Total 384 23 (5.7%) 407 394
Total No DLD 740 64 (8.0%) 804 716 1.423 0.233
DLD 54 2 (3.6%) 56 48
Note: a χ2 test significant at p < 0.05.
11

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12 DO PARENT-REPORTED EARLY INDICATORS PREDICT LATER DEVELOPMENTAL LANGUAGE DISORDER?
before the 1-year follow-up and ≤ 5.0% for all indicators at
the 3-year follow-up.
Since no parent-reported early indicator independently
predicted DLD at 10 years, a cumulative risk index was
created by summing ‘no’ responses to parent-reported
indicators into a continuous variable to determine of a
combination of independent parent-reported indicators
predicted later DLD. The model was non-significant, χ2 (3)
= 0.351, p = 0.950, explaining 0.1% of the variance and cor-
rectly identified 93.6% of the cases, odds ratio (OR) = 0.95,
confidence interval (CI) = 0.85–1.09, p = 0.447. A second
model was run to test for the moderating effect of sex with
the likelihood of presenting with a combination of risk fac-
tors, which was also non-significant, χ2 (6) = 7.617, p =
0.268, explaining 0.2% of the variance, OR = 0.89, CI =
0.59–1.32, p = 0.563.
DISCUSSION
The aim of the current study was to systematically test
the predictive power of parent-reported early indicators
in determining whether a child met criteria for DLD at
10 years in the Raine Study. It is important to note that
identification of DLD in the current study could not
include early onset and functional impact as diagnostic
criteria, and identification was determined by perfor-
mance on standardized tests. This study is an attempt to
elucidate the utility of indicators of early onset to inform
diagnosis while the lack of data on functional impact is
acknowledged as a limitation discussed as future direc-
tions. From birth to 3-year follow-ups, 11 parent-reported
early indicators were leveraged from Raine Study data to
align with those reported in the literature (e.g., Bishop
et al., 2016), including: if the child does not smile or
interact with others, does not babble, makes only a few
sounds, does not understand what others say, says only
a few words, says words that are not easily understood,
and does not combine words or put words together to
make sentences. Family history of speech and/or language
difficulties from either the child’s mother or father were
also included. No one variable indicated a significant
proportion of children with or without DLD; however,
fewer females with DLD at 10 years were reported to
babble late compared to females without DLD.
Some indicators demonstrated proportionate concern
across groups (i.e., smiling ≤ 6 weeks, pointing/looking
at objects when asked ≤ 12 months, and speaking in sen-
tences at 2 years), and there was an overall decrease in
the proportion of concern from the 1-year follow-up (21.7–
51.8%) to 3-year follow-up (≤ 5.0%). This adds weight to
the finding that variability in language performance is
more pronounced in the early years and begins to stabilize
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towards early school age. Of particular interest is the over-
all lack of difference between groups across follow-ups,
suggesting parental concern may be present for children
who go on to have typical language development, and chil-
dren who go on to meet criteria for DLD may not raise
parental concern in the early years.
We also transformed the parent-reported early indi-
cators into a cumulative risk index by summing ‘no’
responses across dichotomous variables into a continuous
variable to determine if a profile that predicted later DLD
could be generated. Results were analysed using the two-
step approach described above to test for the moderating
effects of sex. Findings were also non-significant.
Although the non-significant findings from our analy-
sis of an unselected population-based study is somewhat
surprising, our results may highlight that previous litera-
ture which has reported significant risk factors for DLD
may be subject to retrospective reporting bias. For exam-
ple, Rudolph’s (2017) review was of case history factors,
not exclusively epidemiological population-based studies.
Once Rudolph analysed 11 risk factors for clinical signifi-
cance, the odds of developing DLD (then SLI) with four risk
factors (low maternal education, low 5-min APGAR, later
born sibling and male sex) was as high as the odds as late
talking predicting DLD. Importantly, late talking is not nec-
essarily a reliable predictor of later DLD (e.g., Reilly et al.,
2018). Indeed, population-based studies have found there
are no significant sex differences in those with and without
DLD (e.g., Calder et al., 2022; Norbury et al., 2016; Tomblin
et al., 1997), which suggests that being male is not a risk
factor for DLD—rather, the observed differences in sex in
the current study is likely the result of referral bias, which
is well documented (e.g., Lindsay & Strand, 2016; Morgan
et al., 2017). Therefore, the narrative that males are more
likely to have language disorder must be challenged based
on the overwhelming evidence that may in fact be false.
Such challenges to this narrative will serve only to encour-
age approaches to identify females who are more likely to
go undetected for essential services.
We must also consider that the parent-reported early
indicators leveraged from the Raine Study dataset may
reflect variables that are subject to great variability within
the birth to 3-year span of early development. Therefore,
using parent report as early indicators for later DLD in
isolation may be unreliable through the current methods
of analyses. Recent research has shown promise in more
nuanced approaches to early identification which utilize
standardized assessment and psycholinguistic measures to
complement other risk factors, such as family history in
the early identification of language disorder (e.g., Borovsky
et al., 2021; Sansavini et al., 2021). Therefore, future epi-
demiological research should consider the use of such
measures to complement a measure of overall parental

CALDER et al.
concern in population-based studies, such as the Gen3
Raine Study follow-ups.
Other considerations for discrepancies between our
findings and those previously reported in the literature
are methodological. Even population-based studies of
unselected samples apply different diagnostic criteria to
identify cases of individuals with below expected language
abilities (e.g., Armstrong et al., 2017; Christensen et al.,
2014; Harrison & McLeod, 2010; Norbury et al., 2016; Reilly
et al., 2018; Tomblin et al., 1997) to determine prevalence
and risk factors which may ultimately explain the sig-
nificant variation in the combined samples. Of particular
interest in the current study was the lack of family history
predicting later DLD at 10 years. Christensen et al. (2014)
and Reilly et al. (2018) have found that a positive family his-
tory of language problems may be considered a risk factor
for language problems; however, Bishop et al. (2017) high-
lighted that the predictive power of family history may not
be independently predictive of DLD once other risk factors
have been accounted for (e.g., Botting et al., 2001). The low
predictive power of positive family history problems has
been mirrored in Sansavini et al.’s (2021) recent review and
Borovsky et al.’s (2021) harmonization of large datasets.
Altogether, while the heritability of language disorders has
been demonstrated (e.g., Dale et al., 2003, 2018), the predic-
tive value of family history as an independent predictor of
DLD is likely still debatable.
Clinical implications and future directions
We stress here that red flags should not be ignored as
a standard part of clinical practice and promotion and
prevention strategies in the identification of young chil-
dren who may experience language difficulties in later
childhood. Specifically, parental concern should be con-
sidered foremostly as an indicator for further assessment
and monitoring in clinical practice. We also stress that
the parent-reported indicators included in this study of
children with DLD may be applicable as indicators for
children with language disorders associated with another
condition, so results should not be generalized to other
populations. Conversely, we highlight that the lack of sig-
nificant findings in a large, representative, and unselected
population-based prospective birth cohort suggests an
increased likelihood that DLD may go undetected until
children reach formal schooling. Given the likely referral
bias for males (e.g., Lindsay & Strand, 2016; Morgan
et al., 2017), females may be at particular risk for going
undetected. Equivalent proportions of those with and
without DLD were identified to have showed red flags at
0–3 years (with the exception of late babbling where fewer
parents of females with later DLD expressed concern),
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13
which also means that an equivalent proportion did not
show red flags. DLD may therefore be more insidious
in its presentation until children meet formal schooling.
Consequently, parents and carers must be vigilant when
considering referral, and clinicians should consider the use
of robust and objective measures of language functioning
to complement the evaluation of parental concern.
This study may also run the risk of parent-reporting bias,
in which parents may not have been informed enough
to respond to the probe questions reliably. Indeed, the
crosstabulation of parent-reported concerns in the DLD
sample indicated as few as one case in some instances
(e.g., combining words at 2 years, clear speech at 3 years,
combining sentences at 3 years). Therefore, speech pathol-
ogists and researchers should continue to campaign for
greater advocacy in detecting behavioural determinants of
language difficulties that may manifest as DLD to identify
children as early as possible. Another issue relating to par-
ent report may be that mothers and fathers of children may
not be aware if they had speech and language difficulties
as a child, especially given the propensity for DLD to be
under-identified in childhood (Skeat et al., 2010; Zhang &
Tomblin, 2000). Regardless, we must continue exploring
new methods of detecting DLD and perhaps increase strin-
gency in how speech pathologists and researchers identify
behaviours, both linguistic and non-linguistic, in how we
identify DLD early on.
Calder et al. (2023) presented a range of measures that
map to contemporary diagnostic criteria for the identi-
fication of DLD. The reliability of screening tools that
use measures of sentence recall (e.g., Redmond et al.,
2019) and grammaticality judgement (e.g., Rice et al., 1999)
should be considered as an approach to detect young
children efficiently for further assessment which quan-
tifies language functioning as well as functional impact
through a range of sources. A multidimensional approach
to describe functional impact associated with DLD may
serve to improve participation-based outcomes following
identification (e.g., Cunningham et al., 2017; Washington,
2007). A tool such as the Focus on Outcomes of Communica-
tion Under Six (FOCUS) (Thomas-Stonell et al., 2010) may
therefore be useful for use in the identification and mea-
surement of outcomes for children with DLD in the early
years. Functional impact may also be confirmed through
measures of parental concern, again highlighting the need
for continued attention in this area.
Limitations
Although the Raine Study is a large and representative
prospective pregnancy cohort study (Dontje et al., 2019;
Straker et al., 2017; White et al., 2017), there are limitations

14 DO PARENT-REPORTED EARLY INDICATORS PREDICT LATER DEVELOPMENTAL LANGUAGE DISORDER?
to note regarding the current investigation. Firstly, a lack of
measures of functional impact in the current Raine Study
dataset limits the application of contemporary diagnostic
criteria to the cohort, since the children identified to meet
criteria for DLD in the current study was determined by
scores on standardized assessment in the absence of addi-
tional criteria, including evidence of functional impact and
early onset (APA, 2013; Bishop et al., 2017; WHO, 2019).
This is of particular relevance since fewer females are
identified for clinical services despite comprising equiv-
alent proportions to males meeting diagnostic criteria in
population-based studies. That is, do functional impacts
manifest in ways that are different and less observable
compared to males? Second, there were cases of miss-
ing data for many of the parent-reported early indicators,
which may have resulted in the small number of cases that
indicated concern in the DLD sample. Indeed, the small
number of cases for these variables limited the ability to
reliably test the predictive power of individual variables
indicating DLD at 10 years. Relatedly, the relatively small
sample of children identified with DLD in this study may
increase the risk of type II error for some parent-reported
early indicators, such as word combinations at 2 years. This
also highlights the need to develop robust data collection
methods to evaluate the early onset of language difficulties
in research and clinical practice. Finally, mothers of chil-
dren in the Raine Study were recruited for one hospital in
Western Australia, which may contribute to increased risk
of selection bias in the sample.
CONCLUSIONS
This study systematically tested the predictive utility of
widely used parent-reported early indicators of DLD.
These included if the child did not smile or interact with
others, did not babble, makes only a few sounds, did not
understand what others say, said only a few words, said
words that are not easily understood, and did not put
words together to make sentences between birth and 3
years. Even when considered alongside a family history
of speech and/or language difficulties, data from a large
and representative population-based study indicated that
no one indicator or combination of indicators predicted
DLD at 10 years. Further analyses indicated findings
remained non-significant when testing for the moderating
effects of sex, again reinforcing the utility in being male
as a risk factor for later language disorder is limited.
Previous studies that indicate potential risk factors (such
as being male or family history) in non-epidemiological
studies may be subject to retrospective reporting bias, and
future research and clinical practice should be informed
by recent evidence that highlights promise in the use of
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standardized tests and psycholinguistic measures to
evaluate and complement parental concern in the early
identification of DLD. Such approaches to identification
and assessment should be considered alongside evalua-
tion of functional impact to inform participation-based
interventions.
AC K N OW L E D G E M E N T S
We would like to acknowledge the Raine Study partici-
pants and their families for their ongoing participation
and the Raine Study team for study coordination and data
collection.
Open access publishing facilitated by University of
Tasmania, as part of the Wiley - University of Tasma-
nia agreement via the Council of Australian University
Librarians.
C O N F L I C T O F I N T E R E S T S TAT E M E N T
The authors declare there are no relevant conflicts of
interest.
D A T A AVA I L A B I L I T Y S T A T E M E N T
The data that support the findings of this study are
openly available via application in Raine Study at https://
rainestudy.org.au/information-for-researchers/available-
data/.
ORCID
Samuel D. Calder https://orcid.org/0000-0001-6064-
5837
Mark Boyes https://orcid.org/0000-0001-5420-8606
Elizabeth Hill https://orcid.org/0000-0003-4363-4962
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