Predicting Language at 2 Years of Age: A Prospective Community Study

Sheena Reilly, Melissa Wake, Edith L. Bavin, Margot Prior, Joanne Williams, Lesley
Bretherton, Patricia Eadie, Yin Barrett and Obioha C. Ukoumunne
Pediatrics 2007;120;e1441
DOI: 10.1542/peds.2007-0045

The online version of this article, along with updated information and services, is
located on the World Wide Web at:
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ARTICLE

Predicting Language at 2 Years of Age: A Prospective

Community Study
Sheena Reilly, PhDa,b,c, Melissa Wake, MDc,d,e, Edith L. Bavin, PhDf, Margot Prior, PhDg, Joanne Williams, PhDc,d, Lesley Bretherton, PhDh,
Patricia Eadie, PhDa,c, Yin Barrett, BComm/BScc, Obioha C. Ukoumunne, PhDe,i
a

Schools of Human Communication Sciences and fPsychological Science, La Trobe University, Melbourne, Victoria, Australia; bSpeech Pathology Department, dCentre for
Community Child Health, and hPsychology Department, Royal Childrens Hospital, Parkville, Victoria, Australia; iClinical Epidemiology and Biostatistics Unit,
cMurdoch Childrens Research Institute, Parkville, Victoria, Australia; eDepartment of Paediatrics and gSchool of Behavioural Sciences, University of Melbourne,
Melbourne, Victoria, Australia
The authors have indicated they have no nancial relationships relevant to this article to disclose.

ABSTRACT
OBJECTIVE. This article responds to evidence gaps regarding language impairment
identified by the US Preventive Services Task Force in 2006. We examine the
contributions of putative child, family, and environmental risk factors to language
outcomes at 24 months of age.
METHODS. A community-ascertained sample of 1720 infants who were recruited at 8

months of age were followed at ages 12 and 24 months in a prospective, longitudinal

study in metropolitan Melbourne, Australia. Outcomes at 24 months were parentreported infant communication (Communication and Symbolic Behavior Scales and
MacArthur-Bates Communicative Development Inventories vocabulary production
score). Putative risk factors were gender, preterm birth, birth weight, multiple birth,
birth order, socioeconomic status, maternal mental health, maternal vocabulary and
education, maternal age at birth of child, nonEnglish-speaking background, and
family history of speech-language difficulties. Linear regression models were fitted to
total standardized Communication and Symbolic Behavior Scales and Communicative
Development Inventories vocabulary production scores; a logistic regression model
was fitted to late-talking status at 24 months.
RESULTS. The regression models accounted for 4.3% and 7.0% of the variation in the

24-month Communication and Symbolic Behavior Scales and Communicative

Development Inventories scores, respectively. Male gender and family history
were strongly associated with poorer outcomes on both instruments. Lower Communication and Symbolic Behavior Scales scores were also associated with lower
maternal vocabulary and older maternal age. Lower vocabulary production scores
were associated with birth order and nonEnglish-speaking background. When
the 12-month Communication and Symbolic Behavior Scales Total score was
added as a covariate in the linear regression of 24-month Communication and
Symbolic Behavior Scales Total score, it was by far the strongest predictor.
CONCLUSIONS. These early risk factors explained no more than 7% of the variation in

language at 24 months. They seem unlikely to be helpful in screening for early

language delay.

www.pediatrics.org/cgi/doi/10.1542/
peds.2007-0045
doi:10.1542/peds.2007-0045
Drs Reilly, Bavin, and Prior initiated the
project; Drs Reilly, Wake, and Eadie and Ms
Barrett managed the project, including
data collection and analysis; Dr.
Ukoumunne provided statistical advice
and conducted the analyses; Dr Reilly
wrote the article, and all authors
contributed to planning, reviewing, and
editing the manuscript; and Dr Reilly had
full access to all of the data in the study,
takes responsibility for the integrity of the
data and the accuracy of the data analysis,
and is the guarantor.
Key Words
language development, communication
development, longitudinal study,
risk factors
Abbreviations
USPSTFUS Preventive Services Task
Force
SESsocioeconomic status
ELVSEarly Language in Victoria Study
LGAlocal government area
SEIFASocio-Economic Indexes for Areas
CSBSCommunication and Symbolic
Behaviour Scales
CDIMacArthur-Bates Communicative
Development Inventories
CI condence interval
Accepted for publication May 9, 2007
Address correspondence to Sheena Reilly,
PhD, Speech Pathology Department, Royal
Childrens Hospital, Flemington Road,
Parkville, Victoria 3086, Australia. E-mail:
[email protected]
PEDIATRICS (ISSN Numbers: Print, 0031-4005;
Online, 1098-4275). Copyright 2007 by the
American Academy of Pediatrics

PEDIATRICS Volume 120, Number 6, December 2007

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e1441

RESCHOOL CHILDREN WITH expressive and/or receptive language impairment are at high risk for subsequent difficulties with language and language-related
tasks in their later school careers that, for many, persist
into adulthood.1,2 Much earlier identification would be
ideal to increase the likelihood of altering outcomes by
the preschool years.
Unfortunately, the very limited understanding of the
natural history of language delay from infancy makes
early identification difficult. Wide ranges in the prevalence of language delay are reported, with high rates of
resolution during the early years. At 8 to 10 months of
age, 30% of infants have been reported to have early
delay in communication skills, which persists in 50% to
80% of these children at 2 years of age.3,4 Expressive
language delay, or late talking, reported to affect
15% of 2-year-olds,5 also resolves in 40% to 60% of
children by 3 years and 70% by 4 years of age.6 It is not
possible to identify reliably which trajectory (recovery or
persistence) individual or groups of infants and toddlers
who are at risk for early delay might follow.
The design of effective preventive or treatment programs that target the right children (ie, those who will go
on to have lasting language impairment) must be based
on an understanding of the natural history of language
delay and of the early features that most accurately
identify these children. Although the early markers of
possible later language impairment seem to have reasonable sensitivity, their specificity is uniformly low.4
In 2006, Nelson et al7 published a systematic evidence
review for the US Preventive Services Task Force (USPSTF) on screening for speech and language delay in
preschool children. The review sought to appraise the
strengths and weaknesses of current evidence regarding
the effectiveness of screening and interventions for
speech and language delay. Four of the 8 key questions
addressed in the review concerned screening for early
speech and language delay.7
No studies that directly addressed whether screening
for speech and language delay results in improved
speech, language, or other outcomes were identified;
however, 2 sets of risk factors that might improve the
accuracy of screening were identified. The first set (factors consistently reported in the literature to identify
children at risk) included family history of speech and
language delay, male gender, parent educational levels,
and perinatal factors. The second set (less consistently
reported) included childhood illnesses, later birth order,
family size, older parents or younger mother at birth,
lower socioeconomic status (SES), and minority race.
The task force concluded that the role of these risk
factors in screening was unclear and that a list of risk
factors had not been developed or tested for selective
screening for speech and language delay.7
Only 4811 of the 16 studies reviewed by the USPSTF7
considered risk factors in children who were 24

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REILLY et al

months of age. Of these 4, 1 focused solely on stuttering,9 and the remaining 3 differed markedly in the
speech and language domains studied and in the derivation and composition of the samples. Surprisingly,
none investigated the contribution of gender, SES, birth
order, perinatal factors, or parental education. Family
history was explored in 2 studies, with an association
with language delay found in 111 but not the other.8
There are inherent problems in interpreting published
data on risk factors.4,7 These include the variety of study
designs, the heterogeneity of the populations studied,
variable inclusion and exclusion criteria, and noncomparable outcomes, which makes interpretation and comparison extremely difficult. For example, studies vary in
whether they examine the risk for delay for vocabulary12
speech,13 or language1416 or are still broader and include
stuttering9 or delays in learning.12,1416 Not surprisingly, 1
of the main recommendations from the task force review
was the need for prospective research to identify and
quantify the predictive strength of risk factors in screening for speech and language delay. The study reported
here addresses this recommendation.
This article focuses on quantifying the contributions
made to language outcomes at 24 months of age by the
early risk factors identified by the task force as likely to
influence language development. It builds on a previous
article17 from the same longitudinal study that found
that although a range of child, family, and environmental factors explained a small amount of variation (6%)
in communication skills at 12 months, the strongest
predictor (accounting for 37% of the variation) was
communication development at 8 months of age. The
authors discussed 2 possible explanations for the findings. First, early communication development may have
a substantial biological component, given that so little of
the variability was explained by the combination of factors explored.17 In support of this, recent neuroimaging
studies18 have found decreased white matter volumes in
the motor and language areas of children with developmental language disorder compared with typically developing control subjects. Others have hypothesized that
a common infrastructure that is available to children
equips them to acquire language during early childhood.19 Second, they speculated that as language acquisition stabilized across the first few years of life, it might
become possible to elucidate a combination of early
communication skills and biological and environmental
factors that more reliably predict later language difficulties.17
METHODS
Sampling and Participants
The longitudinal Early Language in Victoria Study
(ELVS) was established in 2002. Sampling methods have
been reported elsewhere.17 Briefly, a community sample

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of infants who were aged 7.5 to 10.0 months were

recruited from 6 of 31 local government areas (LGAs) in
metropolitan Melbourne (population 3.8 million) in the
state of Victoria, Australia. These LGAs were spread geographically across the spectrum of disadvantageadvantage, having been sampled by stratifying the 31 LGAs
into 3 tiers according to the Australian census-based
Socio-Economic Indexes for Areas (SEIFA) Index for
Relative Socio-Economic Disadvantage (representing attributes such as low income, low educational attainment, and high unemployment),20 and then selecting 2
noncontiguous LGAs from each tier.
Between September 2003 and April 2004, potential
study participants were recruited in 1 of 3 ways: via the
Maternal and Child Health nurses; via universally available hearing screening sessions, offered at ages 7 to 9
months; or as a result of publicity. Infants were excluded
when they had developmental delay (eg, Down syndrome), cerebral palsy, or other serious intellectual or
physical disability or when their parents did not speak
and understand English. Participation was maximized by
ensuring that questionnaires were written at no more
than a year 6 reading level. Data were collected on a
broad range of child, family, and environmental factors
at 8, 12, and 24 months of age (data collection from 3
through 7 years is ongoing from 2005 to 2010). This
article draws on communication and language data collected at ages 12 and 24 months and demographic, family, and environmental information collected at ages 8
and 12 months. Figure 1 describes the flow of children
from recruitment through 24 months of age, with those
still participating at 24 months composing the sample on
which these analyses were based.
The ELVS was approved by the ethics committees of
the Royal Childrens Hospital (Melbourne) and La Trobe
University, and all parents provided written, informed
consent.
Outcome Measures
Parents completed the Communication and Symbolic
Behavior Scales (CSBS) Infant-Toddler Checklist21 at
both 12 and 24 months. Standardized total scores (normative mean: 100; SD: 15) and 3 composite scores (normative means: 10; SD: 3) for the domains of social,
speech, and symbolic skills were calculated according to
the manual. The composite domains broadly relate to
infants prelinguistic, linguistic, and cognitive abilities,
respectively, each of which has been demonstrated to
relate to later expressive language development.21 Parents also completed the Words and Sentences version of
the MacArthur-Bates Communicative Development Inventory (CDI) for infants at 24 months.22 To accommodate differences between American and Australian usage, we received permission (from the authors) to
substitute 24 vocabulary items on the Words and Sentences inventory (eg, footpath for sidewalk). Only

Wave 1: Participants at 8 mo (baseline)

N = 1911

Wave 2: Participants at 12 mo
N = 1760
(92.1%)
Wave 3: Participants at 24 mo
N = 1720
(91.1%)

FIGURE 1
Flowchart of the ELVS participants.

the expressive vocabulary production scores were used

in our analyses. Raw (quantitative) scores were calculated for the CDI. As is usual practice with the CDI,
children who were at 10th centile for vocabulary production were identified as late talkers.22
Putative Risk Factors
All putative risk factors identified by the USPSTF were
considered, with the exception of child illnesses (not
collected by the ELVS) and family size (given its high
correlation with birth order during infancy), as shown in
Table 1. Data for the 12 putative risk factors in the ELVS
were drawn from both the 8- and 12-month questionnaires. Our indicator of minority status was whether the
main language spoken in the home to the child was
English or not English, and the indicator of SES was the
continuous SEIFA Index of Relative Disadvantage20 categorized for analysis using quintiles based on SEIFA
values for the Victorian population in 1996 with lower
scores representing greater disadvantage. In addition to
those factors considered by the task force, we studied the
contributions of maternal mental health23 (because maternal depression influences mother child interaction)
and maternal vocabulary (as a proxy for maternal cognition, given the strong heritability of intelligence). Maternal mental health was measured with the Nonspecific
Psychological Distress Scale.24 Scores were divided into
likely mental health problem (a score of 4 of a possible
24) versus no mental health problem (3). Maternal
vocabulary was measured with the written 44-item multiple-choice modified version of the Mill Hill Vocabulary
Scale25 with each correct answer tallied to provide a raw
quantitative score out of the possible 44.
Analysis
Scores on the outcome variables of interest for children
who were born preterm (defined as 36 weeks gestation) were age-corrected before analysis. Random-effects linear regression models26 were fitted to the total
CSBS score, each of the 3 composite CSBS scales, and
the CDI vocabulary score at 24 months, using the 12
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TABLE 1 Comparison of Putative Risk Factors Studied in the ELVS and Those Recommended for Study
by the USPSTF
ELVS

USPSTF

Female gender (yes/no)

Twin birth (yes/no)
Preterm birth (36/36 wk)
Birth weight, kg
Birth order (rst to fth or more)
Not used as highly correlated with birth order
Non-English-speaking background (yes/no)
SES (SEIFA disadvantage score in population quintiles)
Family history speech/language difculties (yes/no)
Maternal mental health problem (yes/no)
Maternal vocabulary score
Maternal education level (12 y reference)
Maternal age at birth of child
NA

Male gender
Perinatal factors
Perinatal factors
Perinatal factors
Birth order
Family size
Minority status
SES
Family history of speech/language difculties
NA
NA
Parents education
Older parents or young mother at birth
Childhood illnesses

NA indicates not applicable.

putative risk factors simultaneously as covariates. The

method allows for potential correlation between the responses of twins. Additional models were then fitted for
each of the CSBS outcomes, identical to the initial models except that the corresponding 12-month CSBS score
was included as an additional covariate to quantify the
extent to which its predictive strength is dominant over
the risk factors. An extended model that included the
12-month CSBS as a predictor was also fitted to the CDI
vocabulary score. A logistic regression model was fitted
to identify which of the risk factors was associated with
late-talking status at 24 months. Information sandwich
estimates of SE27 were calculated for this analysis to
allow for correlation between twins. Again, an additional logistic regression was then fitted with the 12month CSBS total score additionally included as a covariate. Analyses of the 24-month CSBS outcomes were
restricted to cohort members who had their 24-month
assessment between the ages of 23.5 and 25 months, and
those of CDI vocabulary production and late-talking status were restricted to those who completed 24-month
assessments between 23.5 and 25.5 months. Analyses in
which the 12-month CSBS scores were also included as
predictors were further restricted to those who had their
12-month assessment between the ages of 11.5 and 13.5
months. Analyses were implemented by using Stata
9.2.28 R2 values and residual checks for quantitative outcomes were based on ordinary linear regression because
the coefficients were essentially the same as in the random-effects regression models that allowed for correlation between responses from twins. The squared Pearson
correlation measure of R2 was calculated for the logistic
regression analysis.29 Partial R2 values for individual risk
factors are not shown, but their relative predictive
strength may be assessed by ranking the P values in
order of size. Unstandardized coefficients are reported
for the linear regression analyses.
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REILLY et al

RESULTS
Participant characteristics are shown in Table 2. There
were 21 twin pairs in the study and 1 member of another
twin set, making a total of 43 nonsingletons in the study.
The mean (SD) Index for Disadvantage score was 1037.6
(59.7), slightly higher than that for all metropolitan
Melbourne (1020.6 [66.4]); although the spread of values was similar, 80% were in the 3rd, 4th, and 5th (ie,
less disadvantaged) quintiles.
Table 3 summarizes the CSBS standardized scores and
CDI raw vocabulary scores at 24 months. Table 4 shows
the results from the regression analyses for the 24month CSBS total and CDI vocabulary production outcomes. Female gender and higher maternal vocabulary
were associated with higher CSBS scores at 24 months of
age, whereas family history of speech and language difficulties and older maternal age were associated with
lower CSBS scores. Graphic investigation using locally
weighted scatterplots30 suggested that the negative linear
association between maternal age and the CSBS was
mainly for mothers who were 30 years of age. For
younger mothers, there was no marked relationship.
The model fitted to the CSBS total score accounted for
just 4.3% of the variation. Factors that were associated
with higher CDI vocabulary production scores at 24
months included female gender, birth order (being fifth
born), and English-speaking background, whereas family history of speech and language difficulties predicted
lower CDI scores. The model explained 7.0% of the
variation in CDI vocabulary production at 24 months.
A total of 19.7% (333 of 1691) of children were
classified as late talkers. Risk factors associated with latetalking status in the logistic regression analysis (Table 5)
included nonEnglish-speaking background, family history of speech and language difficulties, and low maternal education (12 years). The variation explained by
the model was 4%.

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TABLE 2 Demographic Characteristics of the Participants at 24 Months

Variable

Analysis of CDI (N 1720)a

Analysis of CSBS (N 1680)b

Female gender, n (%)

Twin birth, n (%)
Preterm birth (36 wk), n (%)
Birth weight, mean (SD), kg
Birth order, n (%)
First child
Second child
Third child
Fourth child
Fifth child or more
Non-English-speaking background, n (%)
SEIFA disadvantage quintile, n (%)
1st quintile (most disadvantaged)
2nd quintile
3rd quintile
4th quintile
5th quintile (least disadvantaged)
Family history of speech/language difculties, n (%)
Maternal mental health problem indicated, n (%)
Maternal vocabulary score, mean (SD)
Maternal education level, n (%)
12 y
13 y
University degree
Postgraduate qualication
Maternal age at birth of child, mean (SD), y

844 (49.1)
43 (2.5)
49 (2.8)
3.4 (0.5)

824 (49.0)
43 (2.6)
48 (2.9)
3.4 (0.5)

858 (50.1)
603 (35.2)
206 (12.0)
39 (2.3)
8 (0.5)
101 (5.9)

838 (50.1)
589 (35.2)
204 (12.2)
35 (2.1)
8 (0.5)
97 (5.8)

141 (8.2)
139 (8.1)
456 (26.5)
659 (38.3)
324 (18.8)
424 (24.7)
522 (31.6)
27.6 (5.0)

138 (8.2)
135 (8.0)
448 (26.7)
641 (38.2)
317 (18.9)
419 (24.9)
513 (31.6)
27.7 (5.0)

370 (21.8)
682 (40.2)
407 (24.0)
239 (14.1)
31.3 (4.5)

358 (21.6)
666 (40.2)
398 (24.0)
236 (14.2)
31.3 (4.4)

a Children were included in CDI analysis when aged between 23.5 and 25.5 months at the 24-month follow-up. Denominators in the column
range from 1653 to 1720.
b Children were included in CSBS analysis when aged between 23.5 and 25 months at the 24-month follow-up; these children were also included
in analyses of CDI. Denominators in the column range from 1621 to 1680.

TABLE 3 Summary of 24-Month CSBS (Total and Composite) Standardized Scores and CDI Vocabulary
Production Raw Scores
Variable

Mean (SD)

Median
(Quartiles)

Range

CSBS (N 1677)
Total
Social composite
Speech composite
Symbolic composite
CDI vocabulary production (N 1691)

104.3 (14.8)
10.2 (3.8)
12.8 (4.3)
12.7 (4.0)
260 (162)

103 (94, 114)

10 (8, 12)
11 (9, 17)
11 (9, 17)
247 (126, 376)

65135
317
317
317
0679

Table 6 displays the linear regression models for each

of the 3 CSBS composites (social, speech, and symbolic).
The 12 putative risk factors accounted for 2.5% of the
variation in the social composite score, 6.4% on the
speech composite score, and 7.0% on the symbolic composite score. Higher maternal vocabulary score was the
only factor associated with higher outcome scores on all
3 composites (see Table 3). Two factors, being female
and mothers education level (13 years), were strongly
associated with higher scores on the speech and symbolic composites, whereas having a family history of
speech and language difficulties was associated with
lower scores on both composites.
When the 12-month CSBS total score was included in
the regression model of the 24-month CSBS total score,

it was the strongest predictor (regression coefficient

0.52; 95% confidence interval [CI]: 0.47 to 0.58; partial
R2 19.6%). Similarly, when the models for each of the
24-month CSBS composite scores were adjusted for the
relevant 12-month composite score, the amounts of
variation explained increased (social score: regression
coefficient 0.60, 95% CI: 0.53 to 0.67, partial R2
15.3%; speech score: regression coefficient 0.49, 95%
CI: 0.42 to 0.56, partial R2 9.5%; symbolic score:
regression coefficient 0.48, 95% CI: 0.40 to 0.55,
partial R2 9.1%). When the 12-month CSBS total
score was included as a predictor in the linear regression
of the 24-month CDI score, the corresponding regression
coefficient was 4.9 (95% CI: 4.3 to 5.4) and the partial R2
was 14.2%. Finally, when the 12-month CSBS total
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TABLE 4 Linear Regression of CSBS Total Score and CDI Vocabulary Production at 24 Months
CSBS (N 1562)

Variable
Coefcient
Female gendera
Twin birtha
Preterm birth (36 wk)a
Birth weight, kgb
Birth order (rst child reference)c
Second child
Third child
Fourth child
Fifth child or more
Non-English-speaking backgrounda
SEIFA disadvantage (1st quintile reference)c
2nd quintile
3rd quintile
4th quintile
5th quintile (least disadvantaged)
Family history of speech/language difcultiesa
Maternal mental health problema
Maternal vocabulary scoreb
Maternal education level (12 y reference)c
13 y
University degree
Postgraduate degree
Maternal age at birth of child, yb

95% CI

3.2
2.3
3.3
0.8

1.8 to 4.7
7.1 to 2.6
8.0 to 1.4
2.4 to 0.8

1.1
0.6
0.8
4.4
0.8

0.5 to 2.7
1.8 to 3.0
4.5 to 6.0
7.21 to 16.0
4.31 to 2.7

1.0
0.4
0.7
0.4
2.5
1.2
0.3

2.6 to 4.6
3.3 to 2.5
3.6 to 2.1
2.7 to 3.6
4.2 to 0.8
2.8 to 0.3
0.1 to 0.5

1.1
1.8
3.1
0.3

0.9 to 3.0
0.5 to 4.0
0.5 to 5.6
0.5 to 0.2

CDI (N 1570)
P

Coefcient

95% CI

.001
.36
.17
.31
.70

53.0
45.9
19.2
7.2

37.4 to 68.6
97.7 to 5.9
31.3 to 69.7
9.4 to 23.8

.001
.08
.46
.40
.02

9.7
41.3
38.0
46.8
75.4

27.3 to 7.9
67.0 to 15.5
94.7 to 18.7
78.3 to 172.0
116.3 to 34.5

19.3
9.3
26.4
13.4
45.8
1.1
1.6

58.0 to 19.5
41.2 to 22.6
57.6 to 4.7
47.2 to 20.5
63.9 to 27.7
15.6 to 17.8
0.2 to 3.4

.65
.66

.004
.12
.001
.12

.001

8.4
15.5
8.1
0.6

12.6 to 29.3
8.5 to 39.5
19.6 to 35.7
2.6 to 1.3

.001
.31

.001
.90
.08
.66

.53

a Binary

predictor: regression coefcient represents the mean difference in outcome score between the 2 categories.
b Quantitative predictor: regression coefcient represents the mean increase in outcome score for each unit increase in the predictor.
c Categorical predictor: regression coefcient represents the mean difference in outcome score between the category of interest and the reference category.

TABLE 5 Logistic Regression of Late-Talking Status (<10th Centile on CDI Vocabulary Production) at 24
Months (N 1570)
Variable

OR

95% CI

Female gender
Twin birth
Preterm birth (36 wk)
Birth weight, kg
Birth order (rst child reference)
Second child
Third child
Fourth child
Fifth child or more
Non-English-speaking background
SEIFA disadvantage (1st quintile reference)
2nd quintile
3rd quintile
4th quintile
5th quintile (least disadvantaged)
Family history of speech/language difculties
Maternal mental health
Maternal vocabulary score
Maternal education (12 y reference)
13 y
University degree
Postgraduate degree
Maternal age at birth of child, y

0.86
0.66
1.16
0.92

0.66 to 1.12
0.19 to 2.26
0.44 to 3.00
0.70 to 1.21

.26
.51
.77
.54
.06

1.16
1.81
1.69
0.66
2.48

0.85 to 1.58
1.21 to 2.71
0.71 to 4.04
0.06 to 6.97
1.33 to 4.61

1.17
0.74
1.01
0.77
1.58
1.01
0.98

0.62 to 2.19
0.44 to 1.26
0.60 to 1.68
0.44 to 1.37
1.18 to 2.11
0.76 to 1.34
0.95 to 1.01

0.62
0.67
0.67
1.02

0.44 to 0.87
0.45 to 0.99
0.42 to 1.05
0.99 to 1.05

.004
.24

.002
.96
.18
.04

.27

OR indicates odds ratio.

score was included in the logistic regression model of

late-talking status, it was the strongest predictor (odds
ratio: 0.95; 95% CI: 0.94 to 0.96; partial R2 5.3%).
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REILLY et al

DISCUSSION
When the 12 early risk factors that are widely postulated
to predict language outcomes in preschool children were

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TABLE 6 Linear Regression Analysis of the 3 CSBS Composite Scores at 24 Months (N 1562)
Variable

Social
Coefcient

Female gendera
Twin birtha
Preterm birth (36 wk)a
Birth weight, kgb
Birth order (rst child reference)c
Second child
Third child
Fourth child
Fifth child or more
Non-English-speaking backgrounda
SEIFA disadvantage (1st quintile reference)c
2nd quintile
3rd quintile
4th quintile
5th quintile (least disadvantaged)
Family history of speech/language
difcultiesa
Maternal mental health problema
Maternal vocabulary scoreb
Maternal education level (12 y reference)c
13 y
University degree
Postgraduate degree
Maternal age at birth of the child, yb

95% CI

Speech
P

Coefcient

.10
.39
.07
.05
.04

1.00
0.44
0.13
0.25

0.58 to 1.42
1.83 to 0.95
1.49 to 1.22
0.20 to 0.70

0.24
0.75
0.24
1.40
0.41

0.71 to 0.24
1.44 to 0.06
1.76 to 1.27
1.96 to 4.75
1.43 to 0.60

0.51
0.51
0.62
0.25
0.92

0.32
0.55
1.14
0.41

0.06 to 0.70
1.81 to 0.71
2.37 to 0.09
0.82 to 0.00

0.51
0.89
0.79
0.51
0.15

0.08 to 0.94
0.26 to 1.52
0.58 to 2.17
2.54 to 3.55
0.77 to 1.07

0.22
0.18
0.42
0.22
0.07

0.72 to 1.16
0.94 to 0.59
1.17 to 0.34
1.04 to 0.60
0.51 to 0.37

0.32
0.05

0.73 to 0.08
0.01 to 0.09

0.13
0.03
0.19
0.10

0.39 to 0.64
0.62 to 0.55
0.48 to 0.87
0.15 to 0.06 .001

.75
.47

.76
.12
.03
.86

95% CI

Symbolic
P

Coefcient

.001
.54
.85
.28
.24

1.16
0.43
0.31
0.26

0.78 to 1.55
1.70 to 0.85
1.56 to 0.93
0.15 to 0.68

0.03
0.43
0.26
0.54
0.82

0.47 to 0.40
1.06 to 0.20
1.65 to 1.13
2.54 to 3.62
1.75 to 0.10

1.55 to 0.52
1.35 to 0.34
1.45 to 0.21
1.15 to 0.66
1.41 to 0.44 .001

0.33
0.06
0.50
0.26
0.96

0.62 to 1.28
0.72 to 0.84
0.26 to 1.27
0.57 to 1.09
1.41 to 0.51 .001

0.04
0.10

0.49 to 0.40
0.05 to 0.15

0.54
0.06

0.95 to 0.13
0.02 to 0.11

0.51
1.29
1.14
0.02

0.06 to 1.07
0.65 to 1.94
0.40 to 1.89
0.08 to 0.03

0.37
0.68
1.20
0.01

0.15 to 0.89
0.08 to 1.27
0.52 to 1.88
0.06 to 0.04

.42
.52

.85
.001
.001

.40

95% CI

P
.001
.51
.62
.21
.71

.08
.41

.01
.007
.005

.67

a Binary

predictor: regression coefcient represents the mean difference in outcome score between the 2 categories.
b Quantitative predictor: regression coefcient represents the mean increase in outcome score for each unit increase in the predictor.
c Categorical predictor: regression coefcient represents the mean difference in outcome score between the category of interest and the reference category.

studied concurrently, none was a strong predictor of

communication and vocabulary skills in 24-month-old
children. The variation explained (4.3% and 7.0% for
the CSBS and CDI scores, respectively) in the linear
regression models was shared by the 12 putative risk
factors, and the variation explained by any 1 risk factor
was small. In contrast, communication skills that already
were achieved at 12 months of age explained one fifth of
the variation in 24-month outcomes. Thus, communication score at 12 months was a much better predictor of
outcome at 24 months than the 12 putative risk factors
collectively. Little variation was explained by the risk
factors collectively when considering the outcome of
late-talking status at 24 months.
These findings are in accordance with our previous
report17 in 12-month-old infants. Here we present additional evidence that in a community sample followed
through the first 2 years of life, there seems to be a
strong biological trajectory for communication skill development and vocabulary production that seems relatively unaffected by a range of child, family, and environmental variables.
Our findings are in contrast to much of the published
literature and accepted views on the subject. It seems
that assumptions about risk factors for early language
delay may have been based largely on the studies that
involved older children. In the USPSTF article,7,31 few
studies reviewed considered risk factors in younger chil-

dren (eg, 24 months of age). We suggest that at these

older ages, the evidence remains inconsistent, even for
the 2 most-studied potential risk factors. Of the 9 studies
that investigated family history of speech and language
difficulties, a significant association was reported in 7
(although not all addressed the same speech and language domains); of the 7 that investigated parental education, 5 found an association. It is difficult to interpret
the data on parental education because some studies
measured only maternal education, whereas others considered that of both parents. In 1 study,32 a significant
association was found for maternal but not paternal
education.
Strengths of this study include its prospective, longitudinal design; its community-ascertained sample; and
the young age (8 months) at which participants were
recruited. The findings are likely to be generalizable,
given the community nature of the sample and that the
prevalence of late talkers (19.7%) and spread of CSBS
scores at 24 months of age were broadly similar to those
in other studies.33 Furthermore, this is the first study to
measure concurrently the broad range of variables that
were recently identified as requiring additional study by
a major systematic review.
Relative weaknesses include that although we used
validated measures that are widely considered reliable,
the language outcomes of interest relied solely on parent
report. Face-to-face assessments will be conducted at 4
PEDIATRICS Volume 120, Number 6, December 2007

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e1447

years of age to determine the impact that these factors

have on later language development measured more
objectively. It is possible that as children acquire more
spoken language, risk factors that seemed to contribute
little to development at 12 and 24 months may prove to
be important predictors of language development by 4
years of age. This could partly reflect simple measurement issues: by 4 years, language and communication
development can be formally tested using measures that
are psychometrically more reliable and stable. Furthermore, although children seem to be equipped with the
basic infrastructure and primed to acquire language, activation and acceleration rates may differ during the
early years and may also be disrupted.19 On the basis of
current evidence, we expect that many but not all of our
late-talking 2-year-olds (19.7%) will recover and have
language skills within normal limits at 4 years of age.5,6
Finally, by 4 years of age, definitions of language impairment are much more specific and should improve the
strength of predictive associations.
We were not able to study the impact of childhood
illnesses, although we did include perinatal factors (a
major component of significant early illnesses) and note
that the task force review did not suggest that this was a
strong predictor. It is possible that other important risk
factors that were not studied here exist; however, no
others were obvious either in our own literature review
at the inception of this study in 2001 or in the much
more recent USPSTF review.7
CONCLUSIONS
This comprehensive study indicates that none of the
putative risk factors for early language delay that were
identified through a major systematic review could be
used to predict language outcomes accurately in children
at 24 months of age. Although they may more accurately predict language impairment in older children,
they seem unlikely to be helpful in screening for early
language delay. Two recommendations flow from these
findings. First, we believe that language promotion activities in infants who are younger than 24 months
should be universal or, if targeted, based on the level of
communication skills displayed. Second, additional research should be directed toward defining more tightly
the specific components of infant communicative development that most strongly predict language outcomes in
the toddler and preschool years.
ACKNOWLEDGMENTS
This study was supported by Australian National Health
and Medical Research Council project grant 237106 and
small grants obtained from the Murdoch Childrens Research Institute and the Faculty of Health Sciences, La
Trobe University. Ethical approval was obtained from
the Royal Childrens Hospital Melbourne (23018) and La
Trobe University (0332) human ethics committees.
e1448

REILLY et al

We sincerely acknowledge the contribution of the

Victorian Maternal and Child Health nurses who assisted
with recruitment of the sample, and we thank all of the
participating parents.

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PEDIATRICS Volume 120, Number 6, December 2007

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e1449

Predicting Language at 2 Years of Age: A Prospective Community Study

Sheena Reilly, Melissa Wake, Edith L. Bavin, Margot Prior, Joanne Williams, Lesley
Bretherton, Patricia Eadie, Yin Barrett and Obioha C. Ukoumunne
Pediatrics 2007;120;e1441
DOI: 10.1542/peds.2007-0045
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