AJSLP
Review Article
Case History Risk Factors for Specific
Language Impairment: A Systematic
Review and Meta-Analysis
Johanna M. Rudolpha
Purpose: Research suggests that the best approach to
early identification of children with specific language
impairment (SLI) should include assessment of risk factors.
However, previous attempts to develop a list for this
purpose have been unsuccessful. In this study, systematic
review and meta-analytic procedures were used to determine
whether any case history factors can be used to identify
toddlers at risk of developing SLI.
Method: Epidemiological studies that examined the
association between risk factors and SLI were identified.
Results across studies were aggregated to determine more
precisely the strength of association between each risk factor
and the development of SLI. The clinical significance of these
factors was established via comparison to late talker status.
S
pecific language impairment (SLI) affects ap-
proximately 7.5% of kindergarten-age children
(Tomblin, Records, et al., 1997), which amounts
to at least one and probably two children in every classroom
(RALLIcampaign, 2012). Individuals with SLI experience
significant difficulties learning language, which manifest as
deficits in language comprehension and/or language produc-
tion. Because the ability to understand language and the
ability to communicate through language are so fundamental
to human interaction and learning, such deficits place these
individuals at great risk for poor social, emotional, aca-
demic, and vocational outcomes (Brinton, Fujiki, Spencer,
& Robinson, 1997; Catts, Fey, Tomblin, & Zhang, 2002;
Conti-Ramsden & Botting, 2004; Hadley & Rice, 1991;
Redmond, 2011; Young et al., 2002). It is widely believed
that the earlier that children with communication disorders
receive services and supports, the more likely they are to
achieve successful language and learning skills (Guralnick,
a
University of Texas at Dallas
Correspondence to Johanna Rudolph: johanna.rudolph@utdallas.edu
Editor: Krista Wilkinson
Associate Editor: Laura DeThorne
Received November 18, 2015
Revision received May 13, 2016
Accepted December 13, 2016
https://doi.org/10.1044/2016_AJSLP-15-0181
American Journal of Speech-Language Pathology • Vol. 26 • 991–1010 • August 2017 • Copyright © 2017 American Speech-Language-Hearing Association
Results: Eleven risk factors were found to be
statistically significant predictors of SLI. Among
these, maternal education level, 5-min Apgar score,
birth order, and biological sex met criteria for clinical
significance.
Conclusions: At least 4 case history factors are as
predictive as late talker status in the context of early
identification of toddlers at risk for SLI. The findings of this
review highlight the importance of taking a child’s genetic
and environmental context into consideration when
deciding whether further evaluation and early intervention
services are warranted.
Supplemental Materials: https://doi.org/10.23641/
asha.5150122
2011; Hebbeler et al., 2007). As a result, recommended best
practices for the population of children with SLI include
early identification and early intervention to facilitate
the language learning process during the formative years
of communication development (Olswang, Rodriguez, &
Timler, 1998).
There have been recent efforts in medical and clini-
cal communities to promote early identification of children
with language deficits through detection of early signs and
symptoms of impairment (American Speech-Language-
Hearing Association, n.d.; Hagan, Shaw, & Duncan,
2008). However, many children who present with early
language delays spontaneously recover by the preschool
or early school age years and, therefore, do not have SLI
(Ellis Weismer, 2007; Paul, 1996; Rescorla, 2002). Fur-
thermore, many children with SLI may not exhibit early
language delays (Dale, Price, Bishop, & Plomin, 2003;
LaParo, Justice, Skibbe, & Pianta, 2004; Poll & Miller,
2013). These findings suggest that early language perfor-
mance alone is insufficient to predict which toddlers will
experience significant and chronic difficulties with lan-
guage development.
One potential path forward, suggested in a follow-up
to a systematic review for the U.S. Preventive Services
Disclosure: The author has declared that no competing interests existed at the time
of publication.
991
Task Force, involves consideration of child, parent, or
family characteristics that may place an individual at risk
for long-term impairments (i.e., risk factors; Berkman
et al., 2015). The authors of the review suggested that the
ability to stratify children according to risk might promote
efficient screening, thereby facilitating earlier identification.
Indeed, some studies have found that significantly more
children with SLI are correctly identified when risk factors
are considered alongside early language abilities than when
either risk factors or early language skills are considered
in isolation. For example, in a recent examination of the
American Academy of Pediatrics guidelines for early lan-
guage production milestones, Rudolph and Leonard (2016)
found that lack of word combinations at 24 months was
a significant predictor of later language impairment; how-
ever, this criterion alone only identified about half of the
children with SLI. The authors then examined whether
more children with SLI would be correctly identified if risk
factors were considered in addition to word combining sta-
tus. They found that adding the factor family history of
communication or reading disorders to the predictive model
resulted in the identification of almost 90% of the children
with SLI, significantly more than were identified by word
combining status alone. In a prospective, longitudinal,
population-level study, Reilly et al. (2010) took the oppo-
site approach by first identifying a set of predictive risk
factors. When risk factors were considered in isolation, the
predictive model yielded only a moderate level of discrimi-
nation between children developing typically and those
with SLI. However, when late talker status was combined
with the risk factors, the discrimination of the model im-
proved and, in the case of the expressive SLI group, the
predictive accuracy of the model increased significantly.
Together, the findings of these studies suggest that
the right combination of early behaviors and early risk fac-
tors could yield a simple, efficient, and highly informative
SLI screening tool appropriate for use in clinics and pedi-
atric practices. The first step, then, is to specify which risk
factors are the strongest and most clinically relevant pre-
dictors of the disorder. The purpose of the current study
was to synthesize the available epidemiological data on
SLI risk factors and to determine which of the factors, if
any, are clinically significant predictors of SLI. The ulti-
mate goal of this work is to pave the way to earlier and
more accurate identification of children with chronic and
debilitating language learning deficits.
The Importance of Homogeneity
Risk factor studies have sought to predict a wide
range of language outcomes including expressive vocabu-
lary delay (Fischel, Whitehurst, Caulfield, & DeBaryshe,
1989; Henrichs et al., 2011; Horwitz et al., 2003; Whitehurst,
Smith, Fischel, Arnold, & Lonigan, 1991), late language
emergence (Zubrick, Taylor, Rice, & Slegers, 2007), phono-
logical disorders (Campbell et al., 2003; Fox, Dodd, &
Howard, 2002), low language performance (Choudhury &
Benasich, 2003), vocabulary deficits (Law, Rush, Schoon,
992 American Journal of Speech-Language Pathology • Vol. 26 • 991–1010 • August 2017
& Parsons, 2009), or some combination of language impair-
ments (Dale et al., 2003; Roulstone, Peters, Glogowska, &
Enderby, 2003; Tomblin, Hardy, & Hein, 1991; Zambrana,
Pons, Eadie, & Ystrom, 2014). The deficits associated with
each label vary widely in severity and comorbidity. The pic-
ture is further complicated by the fact that these studies
have differed in sample size, sampling method, participant
ages, factors examined, and analyses used (Berkman et al.,
2015; Harrison & McLeod, 2010). Thus, attempts to develop
a list of risk factors to guide professional practice have met
with a degree of heterogeneity that has precluded the pos-
sibility of meaningful aggregation. To avoid this dilemma
in the current investigation, systematic review procedures
were used to identify a cluster of studies matched on critical
design features. In brief, this review focused on studies con-
taining epidemiological participant samples in which one
portion of the children presented with language impairment
and were characterized as exhibiting SLI whereas another
portion of the children presented with no language impair-
ment and were characterized as typically developing (TD).
Furthermore, particular attention was paid to the types of
risk factors investigated to ensure that those included would
be (a) representative of the range of genetic and environmen-
tal influences that might interact to promote or discourage
child language development (Rogers, Nulty, Betancourt, &
DeThorne, 2015) and (b) obtainable within the context of a
routine pediatric screening. By focusing on studies that satis-
fied these basic requirements, a more homogeneous group
of relatively high quality studies was expected to emerge.
This homogeneity should allow for statistical aggregation of
effect sizes across studies via meta-analysis and quantifica-
tion of the predictive strength of each risk factor.
Clinical Significance
Bothe and Richardson (2011) emphasized the impor-
tance of looking beyond statistical and practical signifi-
cance when examining the results of an intervention study.
They argue that p values and effect sizes do not address
the question of whether the improvement observed over the
course of treatment reflects a meaningful level of change.
The concept of clinical significance has application beyond
the realm of intervention research, however. In all areas of
clinical practice and investigation, it is valuable to know
whether one’s professional approach is meaningful and ap-
propriate. This is usually determined through comparison
to a gold standard—that is, a practice or approach that has
been found to be clinically reliable and is well established
in the field. Within the context of the current review, the
question becomes how do we know that a given risk factor
provides valuable diagnostic information.
Because there is currently no gold standard against
which to compare a given risk factor’s predictive strength,
clinical significance in the current review was judged
against a standard that is frequently used by pediatricians,
child care providers, parents, and researchers to decide
whether further investigation, professional evaluation, or
language services are warranted. This standard is delayed
development of expressive vocabulary skills (i.e., late talk-
ing). Some consider late talking to be a prediagnosis that re-
quires close monitoring and watchful waiting (Paul, 2000),
whereas others view it as a clinical diagnosis that warrants
direct and immediate intervention (The Hanen Centre,
2015). In spite of evidence that reveals the limitations of
this construct as a predictor of SLI (Dollaghan, 2013), late
talking has become a diagnostic phenomenon due to its ac-
cessibility and to the extensive research that has surrounded
it. Given its popularity as an early identification criterion,
late talker status was judged to be an appropriate compari-
son standard for the purpose of the current review. Evidence
that any single case history risk factor is equally or more
predictive than late talker status holds important implica-
tions for clinicians, researchers, and other professionals
interested in early identification of children with language
impairments.
Research Question
In this study, the following question was addressed:
Can specific case history factors be used to identify toddlers
in the general population who are at risk of developing
SLI? This question was examined in two phases. Phase I
focused on determining whether any of the factors examined
in previous research are statistically significant predictors
of SLI. Phase II focused on assessing whether any statisti-
cally significant predictors are also clinically significant.
Method
Search Methods
A three-step approach was used to identify relevant
studies for this review. The first two steps involved data-
base searches; the initial search used broad risk factor ter-
minology and the follow-up search used specific risk factor
terminology. The third step was a systematic hand search
of references extracted from secondary sources identified
during the database searches. These steps are described
briefly below. Additional details can be found in Supple-
mental Materials S1 and S2.
Database Searches
Five electronic databases were searched up to May
2015 for the initial database search and up to March 2016
for the follow-up database search. With the exception of
the search string, procedures were identical across the
searches. No date range was specified to maximize returns.
English-language, peer-reviewed articles were the target of
this review; therefore, books, book chapters, conference
papers, dissertations, and articles not available in English
were excluded. Nonduplicate primary studies were submit-
ted to further evaluation. The full texts of the primary
studies identified during the initial database search were
examined for specific risk factor terms (e.g., family history,
maternal education, socioeconomic status [SES]), which
were used in the follow-up search. Reviews and other sec-
ondary sources were dealt with separately.
Hand Search
Secondary sources identified during the database
searches were the origin of the references examined in the
hand search. All nonduplicate, English-language, journal
article references were extracted from the reference lists of
these secondary sources and entered into a Microsoft Excel
workbook. An automated filter was applied to the titles
to separate out those articles that focused on SLI from
those that did not. The filter was comprised of 23 full or
abbreviated terms that have been used to refer to SLI in
previous research (see Supplemental Material S2). Next,
the abstracts for all of the references that survived title
evaluation were collected and entered into the workbook.
A second automated filter was applied to the abstracts
to distinguish those articles that focused on risk factors
from those that did not. This filter was comprised of
18 full or abbreviated terms that had been used to refer
to risk factors in the abstracts of the articles identified dur-
ing the database searches (see Supplemental Material S2).
Last, the full texts of all remaining articles were obtained
and classified as primary or secondary sources. Primary
studies were submitted to further evaluation.
Reference Evaluation Criteria
The references were evaluated by title, abstract, and
full text. Criteria were established to yield a cluster of
studies matched on certain critical design features. These
design features included: (a) focus on an epidemiological
sample, (b) inclusion of a group of participants consisting
exclusively of children with SLI, (c) examination of one or
more case history risk factors, and (d) provision of odds
ratios (ORs) or enough data to allow for the calculation of
ORs. These four features were selected to align with the
research question: Can specific case history factors be used
to identify toddlers in the general population who are at
risk of developing SLI?
Criterion 1: Epidemiological Sample
The research question establishes the need to make
diagnostic distinctions among members of the general
population. Although sampling bias is a common and fre-
quently cited barrier to external validity in all lines of
human research, it is particularly problematic in studies
that have population-wide decisional implications (Dollaghan,
2015). Such bias can result in patterns of association be-
tween risk factors and outcomes that grossly overestimate
or underestimate true population-level associations (Fletcher,
Fletcher, & Fletcher, 2014). Making a diagnostic decision
on the basis of skewed effects, even at the level of assigning
risk, can have major repercussions for the individual, for
the family, and for society.
In order to limit the influence of sampling bias in the
current review, an effort was made to focus on epidemio-
logical cohorts by evaluating two participant sample char-
acteristics. The first characteristic was whether participants
were recruited using a one-gate or two-gate design (Bossuyt
& Leeflang, 2008). In a one-gate design, the goal is generally
Rudolph: Case History Risk Factors for SLI 993
to obtain a sociodemographically representative sample of
participants by recruiting all of the individuals, for example,
living within a certain geographic region, entering a certain
grade level, or born in a certain hospital in a given year.
Some of these individuals, presumably a small proportion,
will present with disorders and some will not, but partici-
pants are not selected on the basis of the presence or absence
of a diagnosis. In a two-gate design, on the other hand, the
goal is to obtain two separate, and usually matched groups
of participants—one group exhibiting the disorder of inter-
est, the other developing typically. In general, the first group
is obtained through clinical referral, and the second group is
obtained through advertising in local newspapers or through
fliers posted at preschools and daycare centers. Participant
samples recruited by means of a two-gate design are not
intended to be representative of the general population and
are, therefore, much more prone to sampling bias. Thus,
one-gate studies were the focus of the current review.
The second characteristic was whether participants
had been recruited from a special population or from the
general population. It is possible that an investigator might
use a one-gate design to selectively recruit, for example,
babies who were admitted to the neonatal intensive care
unit, children of a multiple birth (e.g., twins), or individ-
uals living in poverty. Selectively recruited samples are, by
definition, going to exhibit some level of sampling bias.
Furthermore, risk-outcome associations may be even more
skewed in these samples given that the participants are
often already at risk for language problems. Thus, studies
that recruited from the general population were the focus
of the current review. By converging on one-gate, general
population study samples, it was anticipated that epidemi-
ological cohorts would be identified.
Criterion 2: SLI
SLI is the outcome of interest specified in the research
question. For the current review, SLI was broadly defined
as a significant impairment in receptive and/or expressive
grammar, morphology, or syntax in the absence of an obvi-
ous cause (e.g., hearing impairment, intellectual disability,
autism spectrum disorder, etc.). This definition, therefore,
excluded children with a primary diagnosis of speech sound
disorder, dyslexia, or pragmatic language impairment, al-
though children with SLI often have comorbid phonologi-
cal, reading, and social difficulties (Leonard, 2014). Within
individual studies, the particular method of diagnosis as
well as the quantity and stringency of SLI exclusionary cri-
teria were left free to vary. These variations were permitted
given that there is currently no standardized method for di-
agnosing SLI (Bishop, 2014); however, the age of diagnosis
was strictly set at 4 years of age or older. This cut-off was
selected because language skills, particularly those aspects
of grammar most affected by SLI, are generally mastered
by this age (Rice, Wexler, & Cleave, 1995), making diagno-
sis of the condition more reliable. Many children diagnosed
with language delays or deficits before the age of 4 years
have been found to spontaneously recover and therefore do
not meet criteria for SLI (Leonard, 2013).
994 American Journal of Speech-Language Pathology • Vol. 26 • 991–1010 • August 2017
Criterion 3: Case History Risk Factors
The research question specifies that case history risk
factors are the exposure of interest. For the current review,
the term risk factor was defined as any prenatal, perina-
tal, neonatal, child, parent, or family characteristic that
might be associated with a child’s language learning abili-
ties (Berkman et al., 2015; Harrison & McLeod, 2010;
Nelson, Nygren, Walker, & Panoscha, 2006; Olswang
et al., 1998). The term case history was used to specify risk
factor accessibility. Risk factors such as birth order and
maternal education level, which can be collected via a
paper and pen questionnaire, are accessible by everyone
and are, therefore, appropriate for routine early identifica-
tion screening purposes. Risk factors such as microdele-
tions on certain genes and abnormal activity or unusual
anatomical symmetry in specified brain regions are only
accessible by those who have the equipment and training
to obtain them. Thus, these risk factors are not appropriate
for routine screening and were not included in the current
investigation. Furthermore, to ensure applicability to early
identification practices, only risk factors that are observ-
able before the age of 3 years were considered. Note that
early developing behaviors, such as babbling, gesture use,
and vocabulary development did not fall under the scope
of this review.
Criterion 4: ORs
Last, the research question indicates that the goal is
to determine the level of risk associated with each factor.
The OR is an effect size that is designed to quantify risk. It
is defined as a measure of association between a given ex-
posure (e.g., later birth order) and an outcome (e.g., SLI).
It is calculated as the odds that the outcome will occur
when an exposure is present over the odds that the outcome
will occur when an exposure is absent. If the odds of devel-
oping the disorder are the same whether or not an individ-
ual is exposed, the calculation yields an OR value of 1.0,
suggesting that the exposure does not increase an individ-
ual’s risk of developing the disorder. If the odds of develop-
ing the disorder are greater among those who are exposed,
the calculation yields an OR value greater than 1.0, sug-
gesting that the exposure increases the individual’s risk of
developing the disorder. If the odds of developing the disor-
der are greater among those who are not exposed, the cal-
culation yields an OR value less than 1.0. In this scenario,
the exposure is protective, which means it decreases an indi-
vidual’s risk of developing the disorder. Although the OR
value provides an estimate of the association between a risk
factor and an outcome for a particular group of partici-
pants, the 95% confidence interval (CI) indicates what the
OR might be within the general population. If the 95% CI
includes the value 1.0, this indicates that there may actually
be no association at the population level. For example, one
study found that the OR corresponding to the risk factor
maternal smoking during pregnancy was 1.60 (Tomblin,
Hammer, & Zhang, 1998), suggesting that the odds of de-
veloping SLI among children whose mothers smoked while
pregnant are 1.6 times higher than the odds of developing
SLI for children whose mothers did not smoke. However,
the 95% CI ranged from 0.90 to 2.50, which includes the
value 1.0. It is necessary to take the 95% CI into account
when assessing statistical or practical significance (Bothe
& Richardson, 2011). This review focused on studies that
either directly provided OR values and 95% CIs for the risk
factors investigated, or provided enough information for
OR values to be calculated. At a minimum, exposure data
for a group with the outcome of interest and exposure data
for a comparison group are needed. For the sake of consis-
tency, TD children—that is, children developing language
normally—were selected as the comparison group in the
current review, so only studies that contained both an SLI
group and a TD group were included.
Reference Evaluation Procedures
These criteria were operationalized to enable exclu-
sion of irrelevant primary studies. Evaluation of titles and
abstracts was undertaken to be highly inclusive, so that
only articles that explicitly addressed topics unrelated to
the research question were eliminated. Full text criteria
were highly stringent to ensure that the final article set sat-
isfied all of the criteria outlined above. See Supplemental
Material S3 for an overview of the specific exclusions ap-
plied at each level.
Title Level
Every reference retrieved from the database searches
and all references that survived the title filter (hand search
references only) were evaluated at the title level. It was
anticipated that information about the nature of the sam-
ple (i.e., Criterion 1) and the statistics reported (i.e., Crite-
rion 4) would not be available in the titles; therefore, the
title exclusions focused on Criteria 2 and 3. In brief, titles
were excluded if they indicated that the article focused
on a disorder other than SLI or on molecular genetics,
neuroanatomy, or neurophysiology.
Abstract Level
Every reference that passed at the title level and sur-
vived the abstract filter (hand search references only) was
evaluated at the abstract level. The same operationalized
criteria served as the basis for abstract exclusion; however,
review of the abstracts revealed that several of the studies
focused on intervention approaches. As intervention does
not satisfy the definition of a case history risk factor, ab-
stracts were also excluded if they referred to intervention
as the independent variable in the study.
Full Text Level
Every reference that passed at the abstract level was
evaluated at the full text level where all four criteria were
represented. In brief, full texts were excluded for using a
two-gate recruitment approach, selectively recruiting from
a special population, not including a group of children
who were diagnosed with SLI after the age of 4 years, fo-
cusing on characteristics, abilities, or traits that fall outside
the definition of case history risk factor, and providing
too little information to identify or calculate OR values.
All primary studies that passed at the full text level were
retained for the systematic review.
Interrater Reliability
Two independent raters were trained on the criteria
and performed interrater reliability for all phases of the ref-
erence evaluation process. Rating occurred consecutively—
that is, the raters first performed reliability on a randomly
selected set of 30% of the titles, then on a randomly se-
lected set of 30% of the abstracts, and, finally, on a randomly
selected set of 20% of the full texts. The reliability work
was divided between the two raters. Reliability was calcu-
lated by dividing the total number of agreements by the
total number of opportunities for agreement. Agreement
for a given reference was defined as a mutual rating of IN
or OUT by both the author and the independent rater.
Across all three steps of the reference search (i.e., initial
database search, follow-up database search, hand search),
total agreement was 95% for titles, 93% for abstracts, and
97% for full texts. Out of 514 opportunities, there were a
total of 27 disagreements. Among these, eight were rated
as OUT by the author and IN by either the first or second
rater, indicating a potential data loss of only 1.6% across
all phases.
Data Extraction
Study Details
The following information was extracted from each
qualifying study: (a) sample size, (b) number of children
with SLI, (c) number of TD children, (d) participant ages,
(e) participant races/ethnicities, (f ) geographical location of
the study population, (g) risk factor information source,
(h) participant diagnostic information source, (i) diagnostic
measure(s) administered, ( j) cut-off score used to classify
children as SLI or TD, (k) naive status of individuals who
reported or collected risk factor or diagnostic information,
and (l) chronology of risk factor report (i.e., prospective
or retrospective). Items (a) through (f ) were extracted for
descriptive purposes and items (g) through (l) for the pur-
pose of quality appraisal.
Risk Factors and OR Values
Risk factors and their corresponding effect sizes were
also extracted. OR values and 95% CIs were the effect
size of interest. Some studies reported adjusted OR values;
some reported unadjusted OR values; some reported fre-
quency data (for dichotomous and categorical risk factors)
or means and standard deviations (for continuous risk
factors), which could be used to calculate unadjusted OR
values; and, finally, some studies reported a mixture of
statistics. Adjusted and unadjusted OR values differ in the
way they are obtained and interpreted. Unadjusted OR
values represent the association between a risk factor and
outcome when no other factors are taken into consideration.
Rudolph: Case History Risk Factors for SLI 995
Adjusted OR values represent the association between the
risk factor and outcome when other potentially confound-
ing variables are controlled for. A confounding variable
is one that is associated with both the risk factor and the
outcome, but is not a mediator in the causal pathway be-
tween the two (Szklo & Nieto, 2007). Take the association
between maternal smoking and SLI. The OR value and
95% CI mentioned previously are unadjusted (see Crite-
rion 4 above); however, the investigators also examined
this association after taking parent education level into
consideration as a confounding variable. In order to per-
form this analysis, they first had to assume that parent
education level is not a causal mediator between maternal
smoking and SLI. This is reasonable given that an ex-
pected causal mediator might be something such as birth
weight—that is, maternal smoking during pregnancy
might be causally associated with a child being born at a
low birth weight, which might then be causally associated
with SLI through a biological mechanism. In contrast,
maternal smoking during pregnancy does not cause less
education, and, therefore, the association between mater-
nal smoking and SLI is unlikely to be causally mediated
by parent education level. It is interesting to note that
when the investigators performed the analysis, the OR
value was reduced and the 95% CI was shifted, suggesting
that parent education level was a confounding variable
in the association between maternal smoking and SLI. Al-
though focusing on adjusted OR values can be instructive,
it can also be misleading if the variables that are chosen
as confounders are, in fact, causal mediators. Because
of the high potential for causal mediation among the risk
factors investigated in this review, unadjusted OR values
were chosen as the primary statistic of interest. As such,
extraction of relevant statistics occurred in the following
sequence: unadjusted OR values, data that could be used
to calculate unadjusted OR values, and adjusted OR
values. Because some studies reported only adjusted
values, analyses were completed to determine whether their
inclusion yielded significant differences in the obtained
results.
Interrater Reliability
An independent observer, naive to the research
question, was trained on the procedures and performed
reliability for 25% of calculated OR values. Four data
points had to be extracted for each reliability item:
(a) number of children with SLI exposed to the risk fac-
tor, (b) number of TD children exposed to the risk factor,
(c) number of children with SLI not exposed to the risk
factor, and (d) number of TD children not exposed to
the risk factor. Agreement was based on an exact match
between the author and independent observer on each
of these four numerical values, and was calculated as
the total number of agreements over the total number
of opportunities for agreement, which came out to 94%.
The disagreements yielded only slight differences, which
had no effect on the final results of the meta-analyses.
996 American Journal of Speech-Language Pathology • Vol. 26 • 991–1010 • August 2017
Quality Appraisal
An adaptation of the Quality Assessment of Diag-
nostic Accuracy Studies–2 (QUADAS-2; Whiting et al.,
2011) was used to appraise the quality of included studies.
The QUADAS-2 is used to characterize the risk of bias
and applicability concerns that may exist in studies investi-
gating the diagnostic accuracy of new assessment instru-
ments. Risk of bias results when there are threats to the
internal validity of a study. An example is test adminis-
tration by an individual who is not naive to participants’
diagnostic status, which could bias the test results. Ap-
plicability concerns result when there are threats to the
external validity of a study. An example is using a non-
traditional diagnostic approach that could not be gener-
alized to clinical practice. The QUADAS-2 focuses on
five key domains: (a) participant selection, (b) index test,
(c) reference standard, (d) participant flow, and (e) timing.
Domains (a) through (c) are assessed for both risk of
bias and applicability concerns, whereas domains (d) and
(e) are assessed only for risk of bias. Studies can be rated
as low, high, or unclear. A low rating is given when risk
of bias and/or applicability concerns are low. The more
low ratings a study receives, the higher the quality. A high
rating is given when risk of bias and/or applicability con-
cerns are high. The more high ratings a study receives,
the poorer the quality. An unclear rating is given when
risk of bias and/or applicability concerns cannot be deter-
mined on the basis of the information provided in the arti-
cle. Unclear ratings indicate the need for more detailed
disclosure of study features related to internal and external
validity.
QUADAS-2 Domain 1: Participant Selection
In order to qualify for the present review, study par-
ticipants had to be recruited using a one-gate design and
not exclusively from a special population. As such, risk of
bias in the domain of participant selection would be likely
only in cases were inappropriate exclusions were applied.
Some inappropriate exclusions include eliminating all chil-
dren from a low-SES background or all those who exhib-
ited borderline language scores. Studies that used these
types of exclusions received a high risk of bias rating for
this domain. Applicability concerns were expected only in
cases where, as a result of errors in recruitment or diagnos-
tic procedures, the proportions of children in the TD or
SLI groups were substantially skewed. Examples of skewed
samples include those exhibiting an SLI prevalence rate
below 3% or over 20% as accepted rates are between 5%
to 15%. Such disproportionality resulted in high applicabil-
ity concern ratings in this QUADAS-2 domain.
QUADAS-2 Domain 2: Risk Factor Collection
For this review, the QUADAS-2 domain, “index
test,” was adapted to apply to risk factor information
collection procedures. In this domain, risk of bias was
associated with the naive status of the individuals reporting
and collecting risk factor information. Studies received high
risk of bias ratings if neither the reporter nor the collector
were naive to the participant’s diagnostic status. Judgment
of applicability concerns focused on the feasibility of the
information collection methods. Studies received high rat-
ings for applicability concerns if, for example, family his-
tory information was collected through direct testing of
all the participant’s family members because this is an ap-
proach that would be impractical to implement in a clinical
setting.
QUADAS-2 Domain 3: Diagnostic Status
The QUADAS-2 domain, “reference standard,” was
adapted to apply to the diagnostic classification procedures
used within the risk factor studies. There were three main
considerations in the diagnostic status domain. The first
two were related to risk of bias and addressed, first, whether
the procedures were valid and likely to correctly classify
children with the target condition and, second, whether the
person administering the assessment or making the diag-
nostic decision was naive to the participant’s risk factors.
Studies in which classification accuracy was dubious because
of the assessment methods used were rated as exhibiting high
risk of bias. In general, if the authors used a standardized
language test with an established cut-off value, risk of bias
was considered low; however, if, for example, classification
was based on subjective observation of symptoms, risk of
bias was considered high. Note that there was no direct
consideration of the psychometric properties of the standard-
ized assessments used. The third consideration addressed
whether the procedures were similar to those that would
be implemented in clinical practice. If the procedures were
unlike typical assessment methods, for example, based
solely on parent report without direct evaluation, the study
received a high rating for applicability concerns.
QUADAS-2 Domain 4: Timing
For the current review, the “timing” domain was
used to refer to the timing of the risk factor report. Infor-
mation could be reported prospectively, meaning that risk
factors such as birth weight, gestational age, and Apgar
score were reported as soon as the information became
available (i.e., birth) and the children were followed for-
ward in time. However, the information could be reported
retrospectively, meaning that caregivers were asked to re-
call events in their child’s life that occurred in the past.
Retrospective reporting can be easily biased by the inaccu-
racy of human memory, especially if parents are looking
for a cause or reason for their child’s difficulties. As a
result, studies that collected risk factor information retro-
spectively received a high risk of bias rating in the timing
domain.
QUADAS-2 Domain 5: Participant Flow
This last domain focused on the loss of participants
from initial recruitment to final analysis. Attrition is com-
mon in prospective longitudinal studies, but systematic
attrition can result in significant differences between the
initial cohort of participants and the sample from which
the final data are drawn. An example of systematic attri-
tion is discontinued participation of individuals from low
socioeconomic backgrounds as a result of lack of resources
or transportation. If statistically significant differences in
demographic, diagnostic, or risk factor characteristics were
found between participants in the initial cohort and the
final sample, the study received a high risk of bias rating
in this domain. Those studies in which differences between
the initial and final samples were not undertaken received
an unclear risk of bias rating.
Data Analysis
Phase I
The goal of Phase I was to determine which risk fac-
tors are statistically significant predictors of SLI. Meta-
analysis is a statistical method by which effect sizes, in this
case OR values and 95% CIs, are aggregated across indi-
vidual studies to produce an estimate that is representative
of the range of effect sizes that may exist for a particular
factor. The aggregated OR value and 95% CI are generally
more precise than the values reported in any single study,
and can therefore be used to make more accurate assess-
ments of a factor’s statistical significance. Thus, in the cur-
rent review, meta-analysis procedures were used to determine
the statistical significance of each eligible risk factor.
Phase II
The goal of Phase II was to determine which statisti-
cally significant risk factors from Phase I are also clinically
significant predictors of SLI. This was accomplished by
comparing the 95% CIs calculated for each significant
risk factor to the 95% CI associated with late talker status.
Thus, late talker status was the standard against which the
clinical significance of each risk factor was judged.
Results
Search Results
Figure 1 provides a flowchart of the reference identi-
fication and evaluation process combining the results
from the initial database search, the follow-up database
search, and the hand search. Ten studies were identified;
however, six of these studies focused on the same popula-
tion of children—that is, the participants from the National
Institute of Deafness and Other Communication Disorders
epidemiological study examining the prevalence of SLI in
kindergarten-age children, hereafter, the EpiSLI cohort
(Fey, Catts, Proctor-Williams, Tomblin, & Zhang, 2004;
Hammer, Tomblin, Zhang, & Weiss, 2001; McGregor,
Oleson, Bahnsen, & Duff, 2013; Tomblin et al., 1998;
Tomblin, Records, et al., 1997; Tomblin, Smith, et al.,
1997). Examination of these articles revealed that the two
most recent studies in the series (Fey et al., 2004; McGregor
et al., 2013) provided risk factor information that entirely
overlapped with the information reported in several of the
earlier studies; however, the samples in the recent studies
were more restricted because of missing data or loss from
Rudolph: Case History Risk Factors for SLI 997
Figure 1. Flowchart of the three-step reference search and evaluation process.

attrition as the participants were followed longitudinally.
Because these studies provided no new information and
represented reduced subsets of the original epidemiological
sample, they were not included in the review. The four
remaining studies in this group each contained some novel,
but also some overlapping risk factor data. This was
addressed during Phase I of data analysis. The four stu-
dies that did not focus on the EpiSLI cohort contained
completely independent samples (Merricks, Stott, Goodyer,
& Bolton, 2004; Reilly et al., 2010; Stanton-Chapman,
Chapman, Bainbridge, & Scott, 2002; Whitehouse, Shelton,
Ing, & Newnham, 2014) leaving a total of eight studies to
include in the meta-analyses.
Data Extraction
Table 1 provides details pertaining to the partici-
pants in the eight included studies. A total of 212,984 chil-
dren, age 4 to 8 years, participated in these studies, 6,275
with SLI and 206,709 developing language normally.
Note that these values took into consideration the fact that
four of the studies focused on the EpiSLI cohort—that is,

998 American Journal of Speech-Language Pathology • Vol. 26 • 991–1010 • August 2017

Table 1. Study population characteristics.

Study N SLI TD Ages Race/ethnicity Location

Hammer et al. (2001)a 1,057 171 886 6 years Unavailable USA

Merricks et al. (2004) 98 33 65 8 years Unavailable UK
Reilly et al. (2010) 1,360 138 1,222 4 years Unavailable Australia
Stanton-Chapman et al. (2002) 207,692 5,862 201,830 6–7 years Unavailable USA
Tomblin, Records, et al. (1997)a 2,009 216 1,793 6 years 83.6% White USA
13.6% African American
2.8% Other
Tomblin, Smith, et al. (1997)a 1,102 177 925 6 years Unavailable USA
Tomblin et al. (1998)a 1,102 177 925 6 years 91.2% White USA
5.1% African American
1.6% Hispanic
2.1% Other
Whitehouse et al. (2014) 1,825 26 1,799 5 years Unavailable Australia

Note. SLI = specific language impairment; TD = typically developing.

a
These studies focused on the National Institute of Deafness and Other Communication Disorders EpiSLI sample.

the totals were calculated including only the sample from
the original study (Tomblin, Records, et al., 1997), and
excluding the samples from the remaining three studies
(Hammer et al., 2001; Tomblin et al., 1998; Tomblin,
Smith, et al., 1997). Only two studies reported participant
race and ethnicity characteristics, and none of the studies
reported dialect variations. All studies took place in
English-speaking countries, five in the United States, in-
cluding the four EpiSLI cohort studies, two in Australia,
and one in the United Kingdom.
Quality Appraisal
Table 2 provides the details concerning research de-
sign features related to the quality of evidence from each
study. Figure 2 summarizes the results of the quality ap-
praisal assessment by domain from the modified version of
the QUADAS-2. Risk of bias was low for all of the stu-
dies in the domain of participant selection, whereas both
risk of bias and applicability concerns were low for the
vast majority of studies in the domains of risk factor col-
lection and assignment of diagnostic status. In contrast,
risk of bias was high in the domain of timing for half of
the studies (three of which focused on the EpiSLI cohort)
due to the high potential for erroneous reporting associ-
ated with retrospective collection of risk factor informa-
tion. Furthermore, the majority of studies were unclear or
exhibited high risk of bias in the domain of participant
flow either because differences between the initial cohort
and final participant sample were not analyzed (unclear)
or differences were analyzed and found to be systematic
(high). Applicability concerns for the domain of partici-
pant selection were high for 35% of the studies due to no-
table disproportionality in the prevalence of SLI within
the participant samples—that is, the prevalence was either
very high or very low compared with accepted population
estimates (see Table 2). Overall, these results suggested
that the quality of the set of included studies was high, but
that risk of bias due to timing of risk factor report and
participant flow was likely to threaten the internal validity
of many studies, whereas under- or overrepresentation of
children with SLI in the participant samples of a few stud-
ies could threaten their external validity.
Phase I Data Analysis
The goal of Phase I was to perform a separate meta-
analysis for each eligible risk factor and to determine
which among them met criteria for statistical significance
(i.e., 95% CI lower limit > 1.0). An overview of this pro-
cess is provided in Figure 3. A total of 162 OR values and
95% CIs distributed across 122 different risk factors were
extracted or calculated from the eight included studies (see
Supplemental Material S4). For the sake of consistency,
values weighted protectively (i.e., OR values < 1.0) were
converted to risk values by means of inversion.
Classification
To be eligible for meta-analysis, a risk factor must
be represented by at least two effect sizes. If a factor is rep-
resented by only one effect size, that effect size is elimi-
nated from further analysis. As a result, 109 out of the
162 effect sizes extracted for the current review would have
been excluded. To prevent major data loss, each effect
size (i.e., OR value and 95% CI) was classified into one of
25 risk categories. For example, effect sizes for long labor,
delivery by forceps, induction, and emergency cesarean
section were classified into the category perinatal event,
whereas effect sizes for per capita income, percentage of
families below poverty, and income-to-poverty ratio were
classified into the category SES. The 25 risk categories
were: biological sex, birth order, birth weight, childhood
chemical exposure, exposure to more than one language,
family history of communication or related disorders, be-
ing formula fed, maternal age at child’s birth, maternal
education level, paternal education level, maternal illness

Rudolph: Case History Risk Factors for SLI 999

Table 2. Quality characteristics.

Risk factor Diagnostic Diagnostic Cut-off Naive

Study SLI source source test score statusa Timing

Hammer et al. (2001)b 16.2% Parent report Direct assessment Batteryc −1.25 SDd Reporter Retrospective
Collector
Assessor
Merricks et al. (2004) 33.7% Parent report Direct assessment CELF-R −1.5 SD Retrospective
Reilly et al. (2010) 10.1% Parent report Direct assessment CELF-P2e −1.25 SD Reporter Prospective
Collector
Stanton-Chapman 2.8% Birth record School system N/A N/A Reporter Prospective
et al. (2002)
Tomblin, Records, 10.8% School record Direct assessment Battery c
−1.25 SD d
Reporter Concurrent
et al. (1997)b Collector
Tomblin, Smith, 16.1% Parent report Direct assessment Batteryc −1.25 SDd Reporter Retrospective
et al. (1997)b Collector
Assessor
Tomblin et al. 16.1% Parent report Direct assessment Batteryc −1.25 SDd Reporter Retrospective
(1998)b Collector
Assessor
Whitehouse et al. 1.4% Parent report and Parent report N/A N/A Reporter Prospective
(2014) medical record

Note. SLI = specific language impairment; CELF-R = Clinical Evaluation of Language Fundamentals–Revised (Semel, Wiig, & Secord, 1992);
CELF-P2 = Clinical Evaluation of Language Fundamentals–Preschool 2 (Wiig, Secord, & Semel, 2006).
a
Three types of naive status were possible given the nature of these studies: (a) naive status of the reporter—the individual reporting risk
factor information was naive to participants’ diagnostic status; (b) naive status of the collector—the individual collecting risk factor information
was naive to participants’ diagnostic status; (c) naive status of the assessor—the individual assigning diagnostic classifications was naive to
participants’ risk factor information. bThese studies focused on the National Institute of Deafness and Other Communication Disorders EpiSLI
sample. cBattery included subtests of the Test of Language Development–Second Edition (TOLD-II:P; Newcomer & Hammil, 1988) and a
narrative task. dOn two out of five tests in the battery. eAustralian adaptation.

during pregnancy, maternal mental health, maternal vo- of a congenital abnormality, presence of a newborn con-
cabulary, minority status, multiple birth, onset of prenatal dition, presence of a pregnancy condition, and SES. This
care, parent marital status, parenting behavior, perinatal approach substantially reduced the number of factors rep-
event, prematurity, prenatal chemical exposure, presence resented by only one effect size.

Figure 2. Quality appraisal results divided according to QUADAS-2 domain. Low ratings indicate good study quality. High ratings indicate
poor study quality. Unclear ratings were assigned when information was not provided and could not be determined.

1000 American Journal of Speech-Language Pathology • Vol. 26 • 991–1010 • August 2017

Figure 3. Overview of Phase I data analysis procedures.
Data Trimming
Once the effect sizes were categorized, data trimming
was undertaken to ensure that the effect sizes falling into
each risk category were independent—that is, derived from
independent participant samples. The three steps in this
process included: (a) eliminating redundant effect sizes,
(b) reducing categorical risk factors, and (c) combining ef-
fect sizes for individual risk factors falling into the same
risk category.
Redundant effect sizes. First of all, the EpiSLI and
Reilly et al. (2010) studies reported redundant effect sizes
for several risk categories. For example, for the category
SES, four nearly identical effect sizes were reported for the
EpiSLI cohort, and two nearly identical effect sizes were
reported for the Reilly et al. cohort. For the EpiSLI cohort,
this phenomenon was the result of the same population
being the focus of four different studies (Hammer et al.,
2001; Tomblin et al., 1998; Tomblin, Records, et al., 1997;
Tomblin, Smith, et al., 1997). For the Reilly et al. cohort,
this phenomenon was the result of the authors reporting
effect sizes separately for overlapping samples (children
with expressive SLI and children with receptive SLI). Alto-
gether, these two studies yielded a total of 52 redundant
effect sizes. To eliminate redundancy in the EpiSLI data,
effect sizes from the oldest studies in the series were retained
for meta-analysis. This approach was taken because the
older studies had larger samples and examined the relevant
factors as they pertained to risk rather than simply report-
ing them as demographic characteristics. All other effect
sizes were excluded. To eliminate redundancy in the Reilly
et al. data, only the effect sizes for the receptive SLI group
were included because that sample was larger, allowing
for consideration of more factors. Together, these exclu-
sions resulted in the removal of 27 redundant effect sizes
leaving a total of 135 OR values and 95% CIs for further
evaluation.
Categorical risk factors. The second step involved re-
ducing categorical risk factors. For example, effect sizes
for maternal education were generally reported separately
for distinct education levels: less than a high school degree,
high school degree, some college, college degree, and ad-
vanced degree. As in this example, there might be up to
five effect sizes representing a categorical risk factor for a
single cohort. The decision of which effect size to select for
meta-analysis was based on the lower limits of the 95%
CIs. Lower limits indicate the minimum degree of associa-
tion between a risk factor and an outcome in the general
population, thus, the greater the lower limit, the greater
the association. For example, in the study by Stanton-
Chapman et al. (2002) the level “less than a high school
degree” was associated with a lower limit of 1.90, whereas
the level “high school degree” was associated with a lower
limit of 1.00. Because 1.90 is greater than 1.00, “less than
a high school degree” was the most predictive level in this
study, and was selected as the representative effect size for
this cohort. Reduction of categorical risk factors resulted
in the removal of 28 effect sizes, leaving 107 OR values
and 95% CIs for further evaluation.
Combined effect sizes. The third step involved combin-
ing effect sizes for individual risk factors in each study that
fell into the same risk category. For example, Whitehouse
et al. (2014) reported separate effect sizes for high maternal
body mass index, hyperemesis, gestational diabetes, threat-
ened abortion, hemorrhage, preeclampsia, and preterm
hospital admission, all of which fell into the risk category
pregnancy condition. Rather than select an individual risk
factor to represent the category, a combined effect size
was calculated using comprehensive meta-analysis (CMA,
2014). Combined OR values represent the average of the
Rudolph: Case History Risk Factors for SLI 1001
individual OR values, whereas combined 95% CIs take
into consideration the variance associated with and the
correlation among the individual OR values. Using this
procedure, 13 combined effect sizes were calculated, which
fell into seven unique risk categories (parenting behavior,
presence of a newborn condition, prenatal chemical expo-
sure, family history of communication or related disorders,
maternal illness during pregnancy, perinatal event, and
presence of a pregnancy condition). Details are reported
in Table 3.
After data trimming was completed, the dataset was
reduced to 52 OR values and 95% CIs. Each of the 25 risk
categories was represented by one or more completely in-
dependent effect sizes.
Finalizing the Risk Factor Set
As mentioned above, risk categories represented by
only a single effect size were ineligible for meta-analysis.
Thus, once the effect sizes were categorized and trimmed,
11 risk categories were excluded. These were childhood
chemical exposure, exposure to more than one language,
being formula fed, maternal mental health, maternal vo-
cabulary, minority status, multiple birth, onset of prenatal
care, parenting behavior, paternal education level, and
presence of a congenital abnormality. After this procedure,
41 OR values and 95% CIs distributed across 14 catego-
ries remained.
Assessing Dataset Suitability
Before meta-analyses were undertaken for the
14 qualifying risk categories, the suitability of the dataset
was assessed. This process involved (a) examining the poten-
tial influence of adjusted effect sizes, (b) considering the
possibility of publication bias, and (c) identifying hetero-
geneity among the effect sizes.
Adjustment. Two of the included studies (Reilly et al.,
2010; Tomblin, Smith, et al., 1997) reported only adjusted
effect sizes for some or all of the investigated risk factors.
In order to examine the effect of adjustment on the meta-
analysis results, two meta-analyses were performed for each
of the associated risk categories. The first analysis contained
all of the reported effect sizes; the second contained only
unadjusted effect sizes. There were no significant differences
between the results of the two approaches; therefore, both
adjusted and unadjusted effect sizes were included in all
remaining analyses.
Publication bias. Every effect size that was eligible
for meta-analysis, whether independently or as part of a
combined effect size, was included in an assessment of pub-
lication bias. Publication bias occurs when the sample of
studies included in a meta-analysis is systematically unrep-
resentative of the range of studies that have investigated
the topic (Rothstein, Sutton, & Borenstein, 2005). Such
bias threatens a review’s validity and may lead to incorrect
and sometimes detrimental conclusions—for example, that
a particular treatment is clinically useful when it is actually
not. Results of a meta-analysis must be interpreted with
caution if bias is discovered. One approach to publication
1002 American Journal of Speech-Language Pathology • Vol. 26 • 991–1010 • August 2017
bias assessment involves plotting standard error, which is
a reflection of sample size, against OR value. Effect sizes
from studies with larger samples appear at the top of the
plot and tend to cluster closely around the mean OR value,
whereas effect sizes from smaller studies appear at the
bottom and tend to be more widely dispersed. This distri-
bution of data points gives the impression of an upside
down funnel (Light & Pillemer, 1984). If the funnel plot
is symmetric around the mean OR value, this suggests that
the set of effect sizes represents an unbiased sample. If,
however, more effect sizes are distributed on one side of
the mean than on the other, this suggests that some effect
sizes are missing and that bias may exist.
The funnel plot can be visually assessed for bias, but
a more objective method involves use of trim and fill im-
putation (Duval & Tweedie, 2000). In this iterative approach,
the most extreme effect sizes on either side of the funnel
plot are systematically “trimmed” from the plot and the
mean OR value is recalculated until the effect sizes are
symmetrically disbursed. During the “fill” phase of this
analysis, the original effect sizes are all replaced, and mirror
effect sizes are imputed on the opposite side of the plot.
This allows for the calculation of a new 95% CI. The sever-
ity of the bias is estimated on the basis of the difference
between the original and imputed values. If the two values
lead to different conclusions, then the impact of bias is
severe. If little to no difference is observed between the
values, the impact of bias is minimal. The results of the
trim and fill imputation procedure for the current review
showed that no effect sizes needed to be trimmed from the
right side of the funnel plot, but 14 effect sizes needed to
be trimmed from the left side in order to form a symmetric
distribution around the mean OR value. During the fill
phase, 14 mirror data points were imputed onto the right
side of the graph. These findings were not surprising given
they are consistent with the approach that was used to
qualify studies for the current review. In particular, only
one-gate designs with general population samples were
accepted, which, in effect, eliminated small case-control
studies that may have yielded large positive effect sizes
(i.e., those in the lower right quadrant of the funnel
plot). The new mean OR value (OR = 1.44, 95% CI [1.33,
1.56]) was larger than the original mean OR value (OR =
1.34, 95% CI [1.23, 1.46]); however, on the basis of the
95% CIs, both values overlapped substantially and were
not significantly different from one another. Thus, the im-
pact of publication bias in the current set of studies was
considered minimal (Rothstein et al., 2005).
Heterogeneity. Heterogeneity statistics for the 14 eli-
gible risk categories were examined. If significant heteroge-
neity exists among effect sizes extracted from individual
studies, it suggests that the association between the risk
factor and outcome varies substantially and nonrandomly
from study to study. As such, the aggregated effect size is
not meaningful. To assess heterogeneity, two statistics,
Q and I2, were examined. Q is a chi-square statistic that
describes the deviation of each individual OR value from
the mean OR value. The larger the Q value, the smaller
Table 3. Combined effect sizes.

Study Risk category Individual risk factors Combined OR Combined 95% CI

Hammer et al. (2001) Parenting behavior Read to child 2.2 [1.15, 4.22]
Tell stories to child
Discuss daily activities
Routine wake time
Family meals
Stanton-Chapman et al. (2002) Newborn condition 5-min Apgar 1.87 [1.30, 2.70]
Anemia, assisted ventilation
Prenatal exposure Maternal tobacco use 1.2 [1.10, 1.32]
Maternal alcohol use
Tomblin, Smith et al. (1997) Family history Maternal 1.65 [1.06, 2.57]
Paternal
Maternal illness Kidney infection 1.09 [0.41, 2.87]
Thyroid issue
Sexually transmitted disease
Urinary tract infection
Perinatal event Cesarean section 0.85 [0.53, 1.38]
Induced labor
Forceps delivery
Labor duration
Birth complications
Pregnancy condition History of poor outcomes 1.07 [0.58, 1.95]
Gestational diabetes
Hypertension
Prenatal exposure Maternal smoking 1.1 [0.68, 1.78]
Paternal smoking
Maternal drug use
Paternal drug use
Maternal alcohol use
Paternal alcohol use
Occupational exposure
Whitehouse et al. (2014) Maternal illness Preexisting diabetes 0.96 [0.10, 9.24]
Kidney infection
Newborn condition Time to spontaneous respiration 1.72 [0.38, 7.84]
Resuscitation
Birth trauma
1-min Apgar
5-min Apgar
NICU placement
Poor sucking/feeding
Hypoglycemia
Jaundice
Anemia
Temperature maintenance
Perinatal event Breech 0.92 [0.24, 3.54]
Induced labor
Maternal fever
Abnormal fetal heart rate
Prostiglandins
Oxytocin
Narcotic analgesia
Epidural analgesia
Atypical placenta
Atypical umbilical cord
Elective cesarean section
Emergency cesarean section
Forceps/vacuum delivery
Labor duration
Expulsion
Pregnancy condition Maternal BMI > 30 0.97 [0.11, 8.99]
Hyperemesis
Gestational diabetes
Threatened abortion
Hemorrhage
Preeclampsia
Hospital admission (< 20 weeks)
Hospital admission (≥ 20 weeks)
(table continues)

Rudolph: Case History Risk Factors for SLI 1003

Table 3. (Continued).
Study Risk category Individual risk factors
Prenatal exposure Maternal alcohol use
Maternal smoking
Note. OR = odds ratio; CI = confidence interval; NICU = neonatal intensive care unit; BMI = body mass index.
the p value, and the greater the degree of heterogeneity
that exists. Because Q can be less sensitive as an indicator
of heterogeneity when the number of included studies is
small, a second heterogeneity indicator was also consid-
ered. I2, or the inconsistency index, describes the percent-
age of variation across effect sizes, which is due to systematic
differences across studies as opposed to the variation that is
due to random sampling error. For the current review, het-
erogeneity was considered significant either when p(Q) ≤ .10
or when I2 > 50. Among the 14 categories that were eligible
for meta-analysis, significant heterogeneity was observed
for birth weight (Q = 14.11, p = .003, I2 = 78.74), maternal
age (Q = 76.15, p = .000, I2 = 96.06), and SES (Q = 8.98,
p = .011, I2 = 77.74). Because significant heterogeneity indi-
cates that these aggregated OR values cannot be interpreted
with confidence, these three categories were eliminated, leav-
ing 11 risk categories for further consideration.
Initial Meta-Analyses
Meta-analyses were performed for the 11 qualifying
risk categories using CMA. Random effects models were
used for these and all remaining analyses. Nine of the cate-
gories were statistically significant (i.e., 95% CI lower limit
> 1.0). Five out of these nine categories had been repre-
sented by at least one combined effect size. These five cate-
gories were family history of communication or related
disorders, perinatal event, prenatal chemical exposure, pres-
ence of a newborn condition, and presence of a pregnancy
condition. This raised the question of whether the signifi-
cance of these categories might actually be due to the signif-
icance of one or more of the individual risk factors that
were combined to create them. To test this possibility, post
hoc meta-analyses of the individual risk factors falling into
these five significant risk categories were performed.
Post Hoc Risk Categories
Because at least two effect sizes are required to per-
form meta-analysis, post hoc meta-analyses could be com-
pleted only for the nine individual risk factors that were
examined in more than one study. These were 5-min Apgar
score, birth complications, cesarean section, delivery by
forceps, gestational diabetes, induced labor, labor dura-
tion, maternal alcohol consumption during pregnancy, and
maternal smoking during pregnancy. These will hereafter
be referred to as post hoc risk categories. Heterogeneity
statistics revealed significant heterogeneity for birth com-
plications (Q = 3.127, p = .077, I2 = 68.02) and labor dura-
tion (Q = 2.90, p = .089, I2 = 65.48). These categories
1004 American Journal of Speech-Language Pathology • Vol. 26 • 991–1010 • August 2017
Combined OR Combined 95% CI
1.51 [0.45, 5.10]
were eliminated, leaving seven post hoc risk categories for
meta-analysis.
Final Meta-Analyses
The aggregated OR values and 95% CIs for the
18 risk categories (i.e., 11 original categories and seven
post hoc categories) were calculated. Among the post hoc
categories, 5-min Apgar score, maternal smoking during
pregnancy, and maternal alcohol consumption during
pregnancy were statistically significant. The original risk
categories into which these had fallen, newborn condition
and prenatal chemical exposure, were reanalyzed excluding
these three factors. This resulted in the elimination of prenatal
chemical exposure from meta-analysis as it was represented
by only one effect size when maternal smoking and maternal
alcohol consumption were treated as independent risk catego-
ries, resulting in 10 original risk categories and seven post
hoc categories (n = 17). Table 4 reports the aggregated effect
sizes and heterogeneity statistics following this modification.
Eleven risk categories were statistically significant: maternal
education level, family history, birth order, biological sex,
prematurity, presence of a newborn condition, presence
of a pregnancy condition, perinatal event, 5-min Apgar
score, maternal smoking during pregnancy, and maternal
alcohol consumption during pregnancy. These risk catego-
ries were retained for Phase II of data analysis.
Phase II Data Analysis
To determine the OR value and 95% CI associated
with late talker status, a group of studies from a recent
review of the late talker literature (Dollaghan, 2013), as
well as more recently published studies that have examined
the association between early vocabulary skills and pre-
school or school age (i.e., 4 years or older) SLI, were iden-
tified (Ellis Weismer, 2007; Grimm & Schulz, 2014; Paul,
2000; Poll & Miller, 2013; Rice, Taylor, & Zubrick, 2008;
Rudolph & Leonard, 2016). An aggregated effect size for
late talker status was calculated using CMA. This yielded
an OR value of 2.29 and a 95% CI of [1.42, 3.70]. The ef-
fect sizes across the included studies were homogeneous
(Q = 6.04, p = .302, I2 = 17.26), which indicates that the
aggregated OR value is a valid representation of the range
of values associated with late talker status. Given these
results, risk categories were considered to be clinically sig-
nificant predictors of SLI if the lower limits of their associ-
ated 95% CIs were ≥ 1.42. A forest plot was created for
the 11 significant risk categories from Phase I (see Figure 4),
which were organized according to the magnitude of the
Table 4. Aggregated odds ratios (ORs), confidence intervals (CIs), and heterogeneity statistics for original and post hoc risk categories.

Effect size Heterogeneity

Category N OR 95% CI Z p (Z ) Q df p (Q) I2

Risk
Maternal education 116,205 2.12 [1.95, 2.31] 17.22 0.000 3.04 3 0.386 1.26
Family history 2,308 1.77 [1.30, 2.40] 3.66 0.000 0.18 1 0.675 0.00
Birth order 162,380 1.70 [1.57, 1.86] 12.29 0.000 0.11 1 0.740 0.00
Biological sex 212,893 1.64 [1.43, 1.89] 7.13 0.000 5.00 4 0.288 19.96
Prematurity 201,939 1.49 [1.34, 1.67] 7.18 0.000 0.55 1 0.460 0.00
Newborn conditiona 195,389 1.41 [1.13, 1.74] 3.09 0.002 0.05 1 0.819 0.00
Parent marital status 195,375 1.40 [0.58, 3.34] 0.75 0.453 1.96 1 0.161 48.99
Pregnancy condition 196,491 1.20 [1.13, 1.27] 5.82 0.000 0.17 2 0.918 0.00
Perinatal event 196,477 1.09 [1.02, 1.17] 2.66 0.008 1.16 2 0.560 0.00
Maternal illness 2,912 1.07 [0.44, 2.16] 0.15 0.884 0.01 1 0.920 0.00
Post hoc risk
5-min Apgar 193,946 2.44 [1.59, 3.72] 4.11 0.000 0.06 1 0.800 0.00
Maternal smoking 196,384 1.28 [1.07, 1.52] 2.74 0.006 2.71 2 0.258 26.12
Maternal alcohol use 196,226 1.18 [1.05, 1.32] 2.84 0.005 1.15 2 0.563 0.00
Induced labor 2,711 1.02 [0.68, 1.52] 0.08 0.937 0.02 1 0.887 0.00
Gestational diabetes 2,911 1.00 [0.49, 2.04] −0.01 0.996 0.00 1 0.984 0.00
Cesarean section 2,913 0.72 [0.50, 1.06] −1.68 0.093 0.33 1 0.565 0.00
Forceps delivery 2,674 0.48 [0.28, 0.84] −2.57 0.010 0.08 1 0.777 0.00

Note. OR = odds ratio; CI = confidence interval. Significant factors (95% CI lower limit > 1.0) are bolded. Among the original 14 risk
categories, birth weight, maternal age, and socioeconomic status are not included due to significant heterogeneity. In addition, prenatal
chemical exposure is not included because it was no longer eligible for meta-analysis after maternal alcohol use and maternal smoking were
analyzed as independent risk factors. Among the nine post hoc risk factors, birth complications and labor duration are not included due to
significant heterogeneity.
a
Does not include 5-min Apgar score.

lower limit of their 95% CIs. The boundary of clinical sig-
nificance was demarcated with a dashed line. Maternal edu-
cation level, 5-min Apgar score, birth order, and biological
sex fell entirely within the boundary of clinical significance.
Family history and prematurity fell almost entirely within
the boundary. Newborn condition and maternal smoking
fell partially within the boundary. Pregnancy condition,
maternal alcohol consumption, and perinatal event all fell
entirely outside the boundary of clinical significance.
Discussion
It is well established that early language performance
alone is insufficient to identify all of the children who will
go on to suffer from severe and chronic difficulties with
language (Dollaghan, 2013; Leonard, 2013). As noted in
previous studies (Reilly et al., 2010; Rudolph & Leonard,
2016), consideration of genetic and environmental factors
may bolster the predictive accuracy of early behavioral
indicators. The purpose of this systematic review was to
synthesize the available data on case history risk factors
for SLI and to examine whether specific factors could be
used to identify toddlers who are most at risk of develop-
ing the disorder. Eleven risk factors emerged as statistically
significant predictors of SLI, and four of these met cri-
teria for clinical significance. These results suggest that the
odds of developing SLI among children whose mothers
have less than a high school degree or who are later born,
male, or scored very low on their 5-min Apgar are as high
as the odds of developing SLI among children who are
late talkers. Of course, this does not imply that all children
who fall into one of these risk categories should be imme-
diately referred for further evaluation and services; none-
theless, this review brings clarity to the question of where
early identification efforts should be directed.
Sources of Heterogeneity
Previous reviews have attempted to develop lists of
risk factors to guide professional decision making in the
context of early speech and language screening (Berkman
et al., 2015; Nelson et al., 2006), but have been unable to
accomplish this goal because of the notable degree of hetero-
geneity encountered across the sets of studies examined. The
current systematic review differs from previous reviews in
that several carefully defined exclusionary criteria were
applied to identify a cluster of studies that were likely to
yield homogeneous outcomes, thereby allowing for statisti-
cal aggregation of results. Although homogeneity was
achieved for the majority of factors, this was not the case
for birth weight, birth complications, labor duration, mater-
nal age, and SES. The observed heterogeneity was unlikely
to be due to differences in diagnosis, sample size, sampling
method, participant ages, or analyses used. Rather, the
heterogeneity was probably the result of discrepancies in
how these particular risk factors were defined. In some cases,
studies assigned nearly opposing meanings to a given factor.
In other cases, differences in risk factor representation—that

Rudolph: Case History Risk Factors for SLI 1005

Figure 4. Forest plot identifying clinically significant risk factors. The dashed line indicates the lower limit for clinical significance (OR > 1.42).
Factors that fall entirely within the shaded area are clinically significant.
is, whether it was characterized dichotomously, catego-
rically, or continuously—contributed to the observed
disparities.
Opposing Meanings
Labor duration was defined as < 2 hr in one study
and as > 10 hr in another. The risks associated with a
short labor are likely to be very different from the risks as-
sociated with a long labor, which could account for the
variability in effect sizes for this risk factor. Neither study
found labor duration to be a significant risk factor for SLI,
and further exploration is not likely to yield different out-
comes. In a similar manner, maternal age was defined as
< 18 years in one study and > 35 years in another. Again,
the risks associated with having a very young mother are
likely to be quite different from the risks associated with
having an older mother. In this case, the former study
found a significant association (OR = 1.60, 95% CI [1.50,
1.80]), suggesting that having a young mother may be a
statistically and even clinically significant predictor of SLI,
whereas having an older mother is not. Studies examining
birth complications were, likewise, on opposite sides of
the spectrum. One study subsumed every sort of possible
birth complication under this category (e.g., placenta pre-
via, breech presentation, fetal distress, etc.), whereas birth
complication was an exclusive category in the second study
and was used to characterize situations that did not involve
cesarean section or labor induction. This factor was sig-
nificant in the first study, but not in the second, suggesting
that some types of birth complications may, in fact, be
associated with SLI, but not others. Indeed, the risk cate-
gory perinatal event was a statistically significant predictor
of SLI; however, the category fell entirely below the boundary
1006 American Journal of Speech-Language Pathology • Vol. 26 • 991–1010 • August 2017
of clinical significance, indicating that these events are
unlikely to be useful predictors in a clinical context.
Differing Characterizations
Birth weight was defined continuously in one study,
categorically in a second, and dichotomously in two others.
Among categorical and dichotomous representations of
this factor, the limit of interest differed from very low birth
weight (< 1,500 g) to low birth weight (< 2,500 g) to small
for gestational age. The effect size associated with very low
birth weight was high (OR = 2.20, 95% CI [1.80, 2.80]), but
the other effect sizes were not significant. SES, in contrast,
was defined continuously in two studies and dichotomously
in a third. The first two studies found this risk factor to be
significantly associated with SLI, whereas the last study did
not. Further consideration of birth weight (categorically
defined) and SES (continuously defined) may be warranted.
Clinical Significance
The 11 statistically significant factors identified in
this review include presence of a pregnancy condition, ma-
ternal smoking during pregnancy, maternal alcohol con-
sumption during pregnancy, perinatal event, prematurity,
presence of a newborn condition, 5-min Apgar score, bio-
logical sex, maternal education level, family history, and
birth order. This suggests that a variety of factors spanning
the range from the earliest stages of fetal development to
the latest stages of language acquisition may have an im-
pact on a child’s language outcomes. Note, however, that
only four out of the 11 factors met criteria for clinical
significance, indicating that not all of these predictors are
reliable enough to be useful within the context of an SLI
early identification screening protocol.
 The four factors that fell entirely within the range
of clinical significance, as well as the two factors that fell
almost entirely within this range, could be quickly and eas-
ily obtained through a parent questionnaire or review of
a child’s medical chart. Furthermore, all of these risk fac-
tors could be identified as early as the day a child is born.
However, when applying the information from this review
in a clinical or research setting, there are three consider-
ations that must be kept in mind. The first is that the four
clinically significant risk factors identified here are only
as informative in an early identification context as late
talker status and should not be given any more or any less
predictive weight. Recall that late talker status, although
widely associated with language impairment by pediatric
professionals, childcare providers, and parents, is not a
strong predictor of SLI (Dollaghan, 2013). Neither is any
one of these risk factors by itself a strong predictor of SLI.
Thus, making diagnostic decisions on the basis of a single
factor or characteristic is never recommended. The second
consideration is that not all risk factors should be weighted
equally. We do not yet know how much predictive power
to assign to the factors individually versus in different com-
binations. For example, what are the odds of developing
SLI for a male child (biological sex) whose father has dys-
lexia (family history) and who is the fourth born in his
family (birth order)? How does this child’s level of risk
compare with that of another child with only one or two
of these risk factors? How does it compare with that of a
child with a completely different set of risk factors? Fur-
ther research is needed to answer these questions and to
provide a validated guide for clinical decision making. The
final consideration, which is closely related to the previous
two, is that children’s early language skills should never
be considered in isolation from their language learning
context. As evidenced in this review, there are a host of
biological, genetic, and environmental factors that are as-
sociated with and might contribute to a child’s language
development (Rogers et al., 2015); every piece of the puzzle
is important when determining which children are most
likely to exhibit poor language outcomes.
Future Research
The results of the study quality assessment suggest
particular considerations for research groups interested in
further exploration of SLI risk factors. The studies in the
current review, with few exceptions, provide excellent
examples of high-quality research in the domains of par-
ticipant selection, risk factor collection, and assignment
of diagnostic status. However, retrospective reporting and
high levels of systematic attrition could have compromised
the internal validity of several studies and led to the wider
CIs obtained for some of the key risk factors. Further-
more, remarkably high or low proportions of children with
SLI could have threatened the external validity of a few
investigations insofar as pockets of children with or with-
out the disorder might have been missed. Thus, in future
research, risk factor information should be collected
prospectively to eliminate bias associated with memory
and outcome awareness; focused attempts should be
made to limit attrition of at risk populations; and, finally,
the sample obtained should be assessed for population
levels of prevalence to ensure that all children, and not
only those at the extremes, are represented and correctly
classified.
Limitations
This review is limited by the following internal con-
straints. First, the primary statistical focus was unadjusted
OR values. This approach was taken because adjusted
values might provide inaccurate estimates of association in
cases where causal mediators are treated as confounding
variables. Nonetheless, unadjusted values might also pro-
vide inaccurate estimates of association if true confounding
variables do exist. Thus, it is possible that the values re-
ported in this review are inflated. Note, however, that the
comparison standard, late talker status, was also repre-
sented by an unadjusted OR value. The comparison is
therefore equivalent, and the main results of the review are
unaffected by this limitation. An additional internal con-
straint involves the fact that the meta-analysis phase was
confined to those risk factors that had been investigated in
two or more studies. Among the 11 risk categories that
could not be included in meta-analysis, five met criteria for
clinical significance within the individual studies that inves-
tigated them. These were childhood chemical exposure,
being formula fed, minority status, paternal education
level, and onset of prenatal care. It is possible that one or
more of these factors might be an important consideration
in the process of determining an individual child’s level of
risk. A third limitation of this study was that aggregated
scores could not be reported for birth weight, birth com-
plications, maternal age, SES, and labor duration as a result
of significant heterogeneity. Results of individual studies
indicate that at least two and possibly three of these factors
may be worthy of further investigation (see Sources of
Heterogeneity above). Last, this review focused on studies
that compared children with SLI to children without lan-
guage impairment. The ability of the examined risk factors
to differentiate between children with different types of
developmental disorders is unknown, although some stud-
ies have begun to explore this topic (Kim, Jeon, Park,
Chung, & Song, 2014).
The review is also externally constrained by limita-
tions of the individual studies. In particular, approximately
75% of the studies suffered from risk of bias in the domain
of participant flow, and applicability concerns were ob-
served for 35% of the participant samples. As such, it is
possible that the populations examined in these studies
were not truly representative, and that findings of this re-
view do not accurately reflect the associations between case
history risk factors and SLI as they exist in the general
population. In addition, although all of the children with
SLI met basic criteria for the disorder, the types of diag-
nostic procedures used and the stringency of exclusionary
Rudolph: Case History Risk Factors for SLI 1007
criteria varied across individual studies. Thus, a child who
met criteria for SLI in one study may not have qualified as
having SLI in another or, alternatively, a child who was clas-
sified as TD in one study may have been diagnosed with SLI
in another. A further external limitation is that the methods
used to assign children to diagnostic categories might have
worked well for monolingual mainstream English-speaking
participants but overestimated the prevalence of SLI among
those children who were from different racial, ethnic, or
language learning backgrounds. As such, the association
between, for example, maternal education or minority status
and SLI may be confounded as a result of language biases
inherent in the assessment instruments that were used. Only
two studies reported information on race/ethnicity, and none
of the studies reported using procedures that were sensitive
to dialect differences. This is a limitation that must certainly
be addressed in future research on this topic.
Conclusions
The findings of this review suggest that at least four
factors—maternal education level, birth order, child’s bio-
logical sex, and 5-min Apgar score—are as clinically rele-
vant as late talker status when it comes to identifying
toddlers who are at increased risk of developing SLI. Al-
though these results cannot be immediately translated to
clinical practice, they do suggest the importance of consid-
ering not only early language skills, but also a child’s ge-
netic and environmental language development context
when deciding who might be most in need of early inter-
vention services. This review lays the groundwork for
further investigation and provides a necessary step in the
process of establishing recommendations for clinical prac-
tice to secure early identification and timely treatment for
children with SLI.
Acknowledgments
Many thanks to Dr. Christine Dollaghan for reviewing drafts
of this article and providing insightful recommendations and helpful
comments. Thanks also to Jennifer King, Mariam Kavakci, and
Simone Crotteau for performing reliability during the reference
evaluation and data extraction phases of this review.
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