What underlies an increased incidence of delayed speech-language development in young children—and how are clinicians handling a spike in referrals? An SLP shares her clinic’s findings and response.
by Liza Stahnke, MS, CCC-SLP, director of clinical operations- Union County
All our lives were rocked by the COVID-19 shutdown of schools and workplaces in 2020, and the repercussions continue. Not always recognized, however, is the magnitude of the shutdown’s impact on the youngest among us.
Standardized test scores of school-age children reveal post-pandemic skill gaps, but is the same true for the toddler and preschool population? The answer is yes, based on what we’ve seen at our clinic, the nonprofit Charlotte (North Carolina) Speech and Hearing Center. Our evaluations of preschoolers indicate a significant jump in communication delays—a pattern seen nationwide, according to research examining children’s developmental and educational scores post-pandemic (see sources).
For example, identification of speech-language delays more than doubled pre- versus post-pandemic among children ages 0–12 years, revealed a March 2023 comparison by Komodo Health. Mirroring what’s happened in our own clinic, the study found the highest risk among the youngest children: Communication-related diagnosis rates increased 107% among preschoolers (ages 3–5), and 136% among infants.
Speech-language pathologists are feeling the effects. In an ASHA survey conducted last year, more than two-thirds (69%) of SLPs surveyed reported an increase in speech-language referrals since 2020. Interestingly, other developmental areas do not appear as affected: One meta-analysis found that communication was the “sole neurodevelopmental domain” at significantly increased risk for impairment among babies in utero or born during the pandemic. Another study found relative advancements in fine-motor skills among infants and toddlers post-pandemic versus pre-pandemic (see sources).
Research is still delving into why we’re seeing disproportionately higher rates of speech-language delays. So far, the picture appears to be complex. Levels of caregiver education and family income appear to play roles, but so do factors related directly to the pandemic itself. These include stress and trauma on families, and strain on educational and health systems. As research continues teasing out these contributing factors, we SLPs face a more immediate task: managing the influx of referrals and young clients. Here’s how our clinic is addressing the burgeoning need, and a look at areas where action and partnering can make a big difference.
A screening mission
Funded by grants from private foundations—the United Way and others—our clinic employs 30 clinicians, of whom 20 are SLPs. Our client population is primarily low-income, Hispanic, and African American families. Each year, our clinic conducts free speech-language screenings, traveling to administer them to approximately 2,000 children, ages 2–5 years, at sites across the Charlotte region.
In the years leading up to 2019, non-pass rates among children we screened had been 20%–22%, consistent within two percentage points. Beginning in the fall of 2020, our identification rates increased by 75%. By 2021, non-pass rates were double the pre-pandemic rates, and have stayed there ever since, at 42%–44%. Closer analyses also reveal some trends within these data: We find a lower likelihood of delayed communication skills among children living in higher-income communities and among those who had consistent access to in-person early-education services during the pandemic’s peak.
The nearby Union County Public Schools report similar patterns. The district’s preschool Exceptional Children’s Department notes an increase in speech-language referrals over the past school year, as well as—notably—a jump in numbers of children meeting IEP eligibility for speech-language intervention.
Why the communication delays?
Increased speech-language delays in this generation of “pandemic babies” cannot be blamed on a single factor. There are likely multiple contributors, including pandemic effects on caregivers, research indicates (see sources). During and following the pandemic, we’ve seen such effects first-hand in families at our clinic, with many caregivers facing stress related to job, child care, and/or income loss. Depending on the caregivers and the situation, this stress could have affected their availability to respond to children’s early communication attempts. In some cases, siblings stepped in as primary caregivers to relieve working parents.
Screen time increased in many households (see “The Complex Question of Screen Influences on Youth”) as caregivers attempted to work from home or access groceries, health care, and other necessary goods and services online. And there tended to be fewer opportunities for in-person language exposure and social interaction like community gatherings, playdates, and outings to grocery stores, libraries, and houses of worship—though all of these have since resumed.
Another possible contributor is the pandemic’s strain on the health care system. While well-child visits with primary care providers continued occurring online, they declined overall among Medicaid-enrolled children—particularly Hispanic, Asian, and urban children, and those older than age 3 years—according to a Kaiser Family Foundation analysis.
The drop in well-child visits likely affected pediatrician referrals to early-intervention programs. Referrals for communication concerns were still happening, but in-person speech-language services were affected, especially during the height of closures and restrictions.
On a positive note, most SLPs transitioned to providing virtual services, and helped many families with this model. Our clinic immediately switched to online services for all our children, across age groups. We found that, overall, virtual therapy worked most successfully with children in higher-income families and with the lowest amounts of need. We also experienced moderate success using virtual coaching of parents to support children ages 0–3.
However, our lower-income families were less able to access virtual services due to limitations such as insufficient equipment, lack of internet bandwidth, low familiarity with technology, and parents working long hours away from home—at construction or grocery store jobs, for example. Academic demands of older siblings attending virtual classes also meant less parental attention for some younger children. And, due to individual differences and developmental factors, not all children engage well with online therapy.
Helpfully, preschools and childcare centers have since reopened for in-person services, though dramatic increases in child care costs—up more than 30 percent since 2019, according to the Bank of America Institute—limit some families’ access to those services.
The good news: Growing awareness
These contributors to young children’s communication challenges are largely out of our hands. But it’s essential to highlight the contributors because they show the need for early identification and intervention, high-quality early childhood education, and SLPs’ involvement in children’s speech-language outcomes.
Encouragingly, there are signs that caregivers may be tuning into children’s developmental concerns earlier. For example, in ASHA’s 2023 survey, roughly two-thirds of SLPs felt families were at least somewhat aware of early identification’s importance. Locally, our clinic sees more parents quickly opting for a full speech-language evaluation after a failed screening than we did immediately post-pandemic. We also see more parents self-referring for an evaluation, rather than waiting for their child’s next pediatrician visit.
Why the quicker action? It could be due to more pandemic-driven awareness of the potential for delays, along with concerns that delaying identification and intervention only hinders a child’s speech-language development. Make no mistake: The “wait and see” approach still exists in both medical offices and families. However—at least in our clinic—more caregivers are seeking help early to maximize the impact of any needed interventions. We’ve had caregivers tell us they notice effects of “lost time” from the past four years, and are eager to help their children close skill gaps, especially before kindergarten.
Ongoing challenge: Overwhelming demand
Not all pandemic ripple effects have been positive, however. First and foremost, the influx of speech-language referrals means a higher need for intervention than our clinicians can accommodate. While the number of children needing our services has doubled or more, the number of providers in the field has not.
We’ve also observed that some children we refer for further evaluation by schools—due to their screening indicating speech-language challenges—are determined not eligible for speech-language intervention. This is because, per qualification criteria for services set by the state, their communication deficits are considered due to “lack of exposure” to high-quality education. The theory is that placement in an education setting can remediate these children’s communication issues, negating the need for skilled intervention.
It certainly makes sense that limited educational and social exposure affects a preschooler’s communication development, but, in some cases, we may run the risk of postponing a child’s need for intervention as language and reading complexity increase. Consider that the biggest increase in communication disorder diagnoses has occurred among children from low-income households—a population already at risk for not meeting educational standards before the pandemic.
Some have proposed managing demand by reconfiguring developmental norms to better reflect preschoolers’ current speech-language status. Theoretically it makes sense to norm skills to same-age peers, but data clearly indicate the pandemic’s unique impact on speech-language relative to other developmental areas. Children’s development itself did not change during the pandemic; their environment did. As our nation returns to pre-pandemic practices, referrals may decrease. Expanding the normal range in our developmental standards would do nothing to advance children’s delayed skills. It could also compromise their ability to meet unchanged expectations of schools, colleges, and employers down the road.
Rewinding to 2019, how would we have responded to the needs of a preschooler from a home with caregivers in crisis, low language exposure, and limited well-child visits? Almost certainly, we would have offered this child and family support. Even in the face of today’s increased challenges, I hope we strive to give families the same degree of support—especially given our knowledge of neurological development, critical windows for language acquisition, and the benefits of early intervention.
What’s next
The increased, positive attention to early intervention and speech-language services following the pandemic is welcome and overdue. The challenge for SLPs, though, is accommodating climbing diagnosis numbers when many of us already have full caseloads. There are no simple solutions to this complex issue, but there are efforts to address it on multiple fronts. In our own practice, we’ve grown our staff by almost 50 percent, expanded our screening and treatment services, and increased the number of children we refer for IEP evaluations.
Broader efforts to address the need include preparation and certification of speech-language pathology assistants, graduating more SLPs from academic programs (see the data cited in “Answers to Your FAQs About Academics and Research”), and starting new communication sciences and disorders master’s programs at regional colleges to staff local schools (watch for a cover story on this topic in the July-August Leader issue).
Meanwhile, other key tools for shoring up children’s foundational communication skills include research, partnerships, and advocacy.
- Longitudinal studies and meta-analyses are helpful for examining pre- and post-pandemic developmental trends and outcomes among toddlers and preschoolers. To inform our treatment planning, we need more data on outcomes of generalized language exposure before access to intervention. Is there a significant difference in long-term social, emotional, and educational results?
- Through partnerships with early childhood classrooms, SLPs can help equip educators with intentional language-building strategies, possibly reducing children’s chances of developing speech-language difficulties. For example, several grants enable our clinicians to teach early childhood educators vocabulary-expansion techniques, speech sound models, pragmatic-language strategies, and other evidence-based approaches. Depending on the setting, child care providers may not be extensively educated in communication development. Providing them—and local teacher education programs—with strategies can help these educators target vulnerable skill gaps among many more preschoolers than one SLP can.
- Advocacy is needed to convince health care insurers to address the doubling of communication disorder diagnosis rates as the public health crisis it is. Currently, many insurance carriers reimburse for speech-language intervention at low rates, or don’t cover it at all. Low reimbursement rates lead to low audiologist and SLP provider participation. This leaves many families to either pick up the cost of care or rely on the education system—starting with Child Find in the preschool years. Even for children with Medicaid coverage, it can be difficult to find providers because of low reimbursement rates (you can consult ASHA’s Medicaid Toolkit, for more information about the Medicaid program). For this reason, ASHA and many state associations, including the North Carolina Speech-Language-Hearing Association (NCSHLA), are advocating for increased reimbursement rates that match the value of our services and enable more families to access quality care. ASHA members who would like improved reimbursement rates in their state, like the advocacy that has been done by NCSHLA and ASHA, can reach out to reimbursement@asha.org to get active.
Building children’s speech-language skills during the sensitive 0–5 developmental window is critical to their social, educational, and workforce success in the future. The mantra “We’re all in this together,” commonly heard during the pandemic, applies just as much today when caring for the youngest members of our communities. Through advocacy and collaboration with health care entities, early education systems, and policy-makers, we collectively have the power to effectively remediate the developmental challenges left in the pandemic’s wake.
This article was originally written for and published in The ASHA Leader‘s May/June 2024 edition. Listen also to ASHA Voices: Conversations on Milestones and Speech-Language Delays, Liza’s podcast interview covering her article.