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Approved by the ASHA Legislative Council, November 2004
This revision was completed by the Ad Hoc Committee for the Review and Revision as Needed of the Preferred Practice Patterns for the Profession of Speech-Language Pathology, which was appointed in 2003. Members of the committee include Ron Gillam (chair), Tempii Champion, Leora Cherney, Nickola Nelson, Mark Ylvisaker, and Janet Brown (ex officio). Celia Hooper, 2003–2005 vice president for professional practices in speech-language pathology, served as monitoring vice president. The committee is indebted to many ASHA members who contributed their expertise in the development or review of this document, including John Riski, Larry Shriberg, Teri Bellis, Alina de la Paz, Travis Threats, and the steering committees of the Special Interest Divisions, and to ASHA staff members from the speech-language pathology and audiology professional practices and multicultural affairs units for their careful review.
The American Speech-Language-Hearing Association (ASHA) established the Preferred Practice Patterns for the Profession of Speech-Language Pathology to enhance the quality of professional services. These statements were developed as a guide for ASHA-certified speech-language pathologists and as an educational tool for other professionals, members of the general public, consumers, administrators, regulators, and third-party payers. The practice patterns apply across all settings in which the procedure is performed and are to be used with sensitivity to and knowledge of cultural and linguistic differences and the individual preferences and needs of clients/patients and their families. In publishing these statements, ASHA does not intend to exclude members of other professions or related fields from rendering services within their scope of practice for which they are competent by virtue of education and training.
The Preferred Practice Patterns provide an informational base to promote delivery of quality patient/client care. They are sufficiently flexible to permit both innovation and acceptable practice variation, yet sufficiently definitive to guide practitioners in decision making for appropriate clinical outcomes. They further provide a focus for professional preparation, continuing education, and research activities. However, the Preferred Practice Patterns are neither a yardstick to measure acceptable conduct nor a set of aspirational principles. Rather, they reflect the normally anticipated professional response to a particular set of circumstances. There may be legitimate reasons for departing from the practice patterns. The ultimate judgment regarding the appropriateness of any given procedure is made by the speech-language pathologist in light of individual circumstances often based on collaborative decision making with the client/patient, family/caregivers, and other professionals. Practitioners, however, need to be aware of the Preferred Practice Patterns, carefully considering the justifications for alternative practices.
These generic and universally applicable practice patterns were developed to be consistent with the World Health Organization's International Classification of Functioning, Disability and Health (WHO, 2001) as well as the framework of the Scope of Practice for Speech-Language Pathology (ASHA, 2001). For each procedure, the Preferred Practice Patterns for the Profession of Speech-Language Pathology specify the professionals who perform the procedure, expected outcome(s), clinical indications for the procedure, clinical processes, setting and equipment specifications, safety and health precautions, and documentation. Adherence, however, to the Preferred Practice Patterns for the Profession of Speech-Language Pathology does not guarantee a desired outcome.
It is useful to regard these practice patterns within a conceptual framework of ASHA policy statements that range in scope and specificity. Figure 1 illustrates these categories of policy statements for professional practice from broad to narrow in scope, and general to detailed in content, within the context of the ASHA Code of Ethics (2003). These categories are defined as follows:
Scope of Practice Statement: A list of professional activities that define the range of services offered within the profession of speech-language pathology.
Preferred Practice Patterns: Statements that define generally applicable characteristics of activities directed toward individual patients/clients and that address structural requisites of the practice, processes to be carried out, and expected outcomes.
Position Statements: Statements that specify ASHA'spolicy and stance on a matter that is important not only to the membership but also to other outside agencies or groups.
Practice Guidelines: A recommended set of procedures for a specific area of practice, based on research findings and current practice. These procedures detail the knowledge, skills, and/or competencies needed to perform the procedures effectively.
In applying the practice patterns, all ASHA members and ASHA-certified professionals are bound by the ASHA Code of Ethics. All professional activity is consistent with the Code of Ethics. Particularly relevant to clinical practice are those provisions for holding paramount the welfare of persons served and providing only those clinical services for which one is competent, considering education, training, and experience.
The original Preferred Practice Patterns (approved by the ASHA Legislative Council in 1992) addressed the professions of speech-language pathology and audiology and were the product of extensive peer review by all segments of the professions of speech-language pathology and audiology. In clinical areas of controversy, working groups were formed to reach consensus on accepted practice patterns. The 1997 version and the current version of the Preferred Practice Patterns for the Profession of Speech-Language Pathology address only the profession of speech-language pathology and were revised by an ad hoc committee of ASHA members in collaboration with expert members as individuals or groups. Each version was circulated for select and widespread peer review by speech-language pathologists and audiologists. As a result, the practice patterns represent the consensus of the members of the professions after they considered available scientific evidence, existing ASHA and related policies, current practice patterns, expert opinions, and the collective judgment and experience of practitioners in the field. Requirements of federal and state governments and accrediting and regulatory agencies also have been considered.
The Preferred Practice Patterns reflect current practice based on available knowledge. Because speech-language pathology is a dynamic and continually developing profession, advances are expected to change current practice patterns. Similarly, advances in educational and health care policy and practices influence professional practices. The practice patterns are updated periodically to reflect new clinical, scientific, and technological developments that occur inside and outside the profession of speech-language pathology.
American Speech-Language-Hearing Association. (1987). Classification of speech-language pathology and audiology procedures and communication disorders. Asha, 29, 49-53.
American Speech-Language-Hearing Association. (1993). Definitions of communication disorders and variations. Asha, 35(Suppl. 10), 40-41.
American Speech-Language-Hearing Association. (2001). Scope of practice in speech-language pathology. Rockville, MD: Author.
American Speech-Language-Hearing Association. (2002). Knowledge and skills for supervisors of speech-language pathology assistants. ASHA Supplement, 22, 113-118.
American Speech-Language-Hearing Association. (2003). Code of Ethics (revised). ASHA Supplement, 23, 13-15.
American Speech-Language-Hearing Association. (2004). Guidelines for the training, use, and supervision of speech-language pathology assistants. Rockville, MD: Author.
American Speech-Language-Hearing Association. (2004). Knowledge and skills needed by speech-language pathologists and audiologists to provide culturally and linguistically appropriate services. ASHA Supplement 24, 152-158.
American Speech-Language-Hearing Association. (2004). Position statement for the training, use, and supervision of support personnel in speech-language pathology. Rockville, MD: Author.
American Speech-Language-Hearing Association. (2004). Scope of practice in audiology. ASHA Supplement 24, 27-35.
World Health Organization. (2001). International classification of functioning, disability and health. Geneva, Switzerland: Author.
Speech-language pathologists providing specific services hold the appropriate credentials, including ASHA certification, and have pertinent training and experience.
Speech-language pathology assistants who provide screening and/or intervention services do so under the supervision of an ASHA-certified speech-language pathologist (in accordance with the current Guidelines for the Training, Credentialing, Use, and Supervision of Speech-Language Pathology Assistants). The speech-language pathologist who supervises speech-language pathology assistants maintains full responsibility for the quality and appropriateness of services provided to the patient/client.
Speech-language pathologists may provide services as part of a collaborative team.
Comprehensive assessment, intervention, and support address the following components within the World Health Organization's International Classification of Functioning, Disability, and Health (2001) framework.
Body structures and functions:
Identify and optimize underlying anatomic and physiologic strengths and weaknesses related to communication and swallowing effectiveness. This includes mental functions such as attention as well as components of communication such as articulatory proficiency, fluency, and syntax.
Activities and participation, including capacity (under ideal circumstances) and performance (in everyday environments):
Assess the communication and swallowing-related demands of activities in the individual's life (contextually based assessment);
Identify and optimize the individual's ability to perform relevant/desired social, academic, and vocational activities despite possible ongoing communication and related impairments;
Identify and optimize ways to facilitate social, academic, and vocational participation associated with the impairment.
Contextual factors, including personal factors (e.g., age, race, gender, education, lifestyle, and coping skills) and environmental factors (e.g., physical, technological, social, and attitudinal):
Identify and optimize personal and environmental factors that are barriers to or facilitators of successful communication (including the communication competencies and support behaviors of everyday people in the environment).
Services may result in a diagnosis of a communication disorder, identification of a communication difference, prognosis for change (in the individual or relevant contexts), intervention and support, evaluation of their effectiveness, and referral for other assessments or services as needed.
Although the outcomes of speech, language, or hearing services may not be guaranteed, a reasonable statement of prognosis is made to referral sources, clients/patients, and families/caregivers.
Outcomes of services are monitored and measured in order to ensure the quality of services provided and to improve the quality of those services.
Appropriate follow-up services are provided to determine functional outcomes and the need for further services after discharge.
Screening services are used to identify individuals with potential communication or swallowing disorders.
Assessment services are provided as needed, requested, or mandated or to rule in or out a specific disabling condition.
Intervention and consultation services are provided when there is a reasonable expectation of benefit to the patient/client in body structure/function and/or activity/participation.
Comprehensive assessment, intervention, and support address the components within the World Health Organization's International Classification of Functioning, Disability and Health (2001) framework, as described previously.
Services are consistent with the best available scientific and clinical evidence in conjunction with individual considerations.
Assessment may be static (i.e., using procedures designed to describe structures, functions, and environmental demands and supports in relevant domains at a given point in time) or dynamic (i.e., using hypothesis testing procedures to identify potential for change and elements of successful interventions and supports).
Services address patient/client and family preferences, goals, and special needs to enhance participation and improve functioning in life activities that the patient/client, family, and others deem important. Materials and approaches have ecological validity in that they are appropriate to the patient's/client's chronological and developmental ages; medical status; physical and sensory abilities; education; vocation; cognitive status; and cultural, socioeconomic, and linguistic backgrounds.
Counseling and consultation are essential components that address the nature and impact of the disorder or difference and engage the patient/client, family/caregiver, and others (e.g., teachers, employers, peers) in the clinical process, as appropriate.
Services may include instruction of communication partners (e.g., family/caregivers, peers, educators) in how to facilitate functioning, remove communication barriers, and enhance participation.
A variety of service delivery models and supports may be utilized, including direct service (e.g., pullout, individual, small group, classroom, community settings); indirect service through consultation and collaboration; service by support personnel with appropriate supervision; service by transdisciplinary or interdisciplinary teams; and service mediated by technology (e.g., telepractice).
Settings for assessment, intervention, and support are selected on the basis of intervention goals and in consideration of the World Health Organization (WHO) framework described above. There is a plan to generalize and maintain intervention gains that includes references to relevant settings and activities.
Telepractice (i.e., telehealth) may be used, when appropriate, to overcome barriers to accessing service caused by distance, unavailability of specialists and subspecialists, or impaired mobility.
All services ensure the safety of the patient/client and clinician and adhere to universal health precautions (e.g., prevention of bodily injury and infectious disease transmission).
Equipment is maintained according to manufacturer's specifications and recommendations. Instruments are properly calibrated, and calibration records are maintained.
Decontamination (e.g., cleaning, disinfection, or sterilization) of multiple-use equipment before reuse is carried out according to facility-specific infection control policies and manufacturer's instructions.
Speech-language pathologists prepare, sign, and maintain, within an established time frame, documentation that reflects the nature of the professional service.
Results of assessment and treatment are reported to the patient/client and family/caregivers, as appropriate. Reports are distributed to the referral source and other professionals when appropriate and with written consent.
The privacy and security of documentation are maintained in compliance with the regulations of the Health Insurance Portability and Accountability Act (HIPAA), Family Educational Rights and Privacy Act (FERPA), and other state and federal laws.
Except for screenings, documentation addresses the type and severity of the communication or related disorder or difference, associated conditions (e.g., medical or educational diagnoses) and impact on activity and participation (e.g., educational, vocational, social).
Documentation includes summaries of previous services in accordance with all relevant legal and agency guidelines.
American Speech-Language-Hearing Association. (1985, June). Clinical management of communicatively handicapped minority language populations. Asha, 27(6).
American Speech-Language-Hearing Association. (1987). Classification of speech-language pathology and audiology procedures and communication disorders. Asha, 29, 49-53.
American Speech-Language-Hearing Association. (1993). Definitions of communication disorders and variations. Asha, 35(Suppl. 10), 40-41.
American Speech-Language-Hearing Association. (2001). Scope of practice in speech-language pathology. Rockville, MD: Author.
American Speech-Language-Hearing Association. (2002). Knowledge and skills for supervisors of speech-language pathology assistants. ASHA Supplement 22, 113-118.
American Speech-Language-Hearing Association. (2003). Code of Ethics (revised). ASHA Supplement, 23, 13-15.
American Speech-Language-Hearing Association. (2004). Guidelines for the training, use, and supervision of speech-language pathology assistants. Rockville, MD: Author.
American Speech-Language-Hearing Association. (2004). Knowledge and skills needed by speech-language pathologists and audiologists to provide culturally and linguistically appropriate services. ASHA Supplement 24, 152-158.
American Speech-Language-Hearing Association. (2004). Position statement for the training, use, and supervision of support personnel in speech-language pathology. Rockville, MD: Author.
American Speech-Language-Hearing Association. (2004). Scope of practice in audiology. ASHA Supplement 24, 27-35.
World Health Organization. (2001). International classification of functioning, disability and health. Geneva, Switzerland: Author.
Speech-language screening in the pediatric population is a pass/fail procedure to identify infants, toddlers, children, or adolescents who require further speech-language/communication assessment or referral to other professional and/or medical services.
Pediatric speech-language screening is conducted according to the Fundamental Components and Guiding Principles.
Pediatric speech-language screening is conducted by appropriately credentialed and trained speech-language pathologists, possibly supported by speech-language pathology assistants under appropriate supervision.
Pediatric speech-language screening identifies infants, toddlers, children, or adolescents likely to have speech-language and communication impairments that may interfere with body structure/function and/or activity/participation as defined by the World Health Organization (WHO) (see Fundamental Components and Guiding Principles).
Screening services result in pass/fail decisions and may result in —
recommendations for supporting normal development and preventing speech language impairment;
referral for comprehensive speech-language assessment or other assessments or services;
plans to monitor development.
Pediatric speech-language screening services are provided to infants, toddlers, children, adolescents, and their families as needed, requested, or mandated, or when other evidence suggests that they have risks for speech-language disorders associated with their body structure/function and/or activities/participation.
Pediatric speech-language screening services are provided with parental consent as mandated by federal, state, and or local regulations.
Screening services are sensitive to cultural and linguistic diversity. Screening includes a range of age-appropriate, speech-language and other communication functions and activities.
Standardized (e.g., normed screening tests) or nonstandardized methods (e.g., criterion-referenced assessments, parent interviews, classroom observations) are used to screen oral motor function, communication and social interaction skills, speech production skills, comprehension and production of spoken and written language (as age-appropriate), and cognitive aspects of communication.
Screening typically focuses on body structures/functions but may also address activities/participation, and contextual factors affecting communication.
Individuals who fail the screening are referred to a speech-language pathologist for further assessment.
Setting: Pediatric speech-language screening is conducted in a clinical or educational setting or other natural environment conducive to valid screening results. Settings for screening may include hospitals, clinics, schools, or homes.
Equipment Specifications: All equipment used for pediatric speech-language screening is used and maintained in accordance with the manufacturer's specifications.
Safety and Health Precautions: All screening services ensure the safety of the patient/client and clinician and adhere to universal health precautions (e.g., prevention of bodily injury and transmission of infectious disease). Decontamination, cleaning, disinfection, and sterilization of multiple-use equipment before reuse are carried out according to facility-specific infection control policies and services and according to manufacturer's instructions.
Documentation includes a statement of identifying information, screening results, and recommendations, indicating the need for rescreening, assessment, or for a referral.
The privacy and security of documentation are maintained in compliance with the regulations of the Health Insurance Portability and Accountability Act (HIPAA), the Family Educational Rights and Privacy Act (FERPA), and other state and federal laws.
Results of screening are reported to child's family/caregivers, as appropriate. Reports are distributed to referral source and other professionals when appropriate and with written consent.
American Speech-Language-Hearing Association. (1988, March). Prevention of communication disorders: Position statement. Asha, 30, 90.
American Speech-Language-Hearing Association. (1993). Definitions of communication disorders and variations. Asha, 35(Suppl. 10), 40-41.
American Speech-Language-Hearing Association. (2004). Admission/discharge criteria in speech-language pathology. ASHA Supplement 24, 65-70.
World Health Organization. (2001). International classification of functioning, disability and health. Geneva, Switzerland: Author.
Speech-language pathology screening in adults is a pass/fail procedure to identify individuals who require further speech, language, and/or cognitive assessment or referral for other professional and/or medical services.
Speech-language pathology screening in adults is conducted according to the Fundamental Components and Guiding Principles.
Screening is conducted by appropriately credentialed and trained speech-language pathologists, possibly supported by speech-language pathology assistants under appropriate supervision.
Speech-language pathology screening identifies persons who are likely to have speech, language, and cognitive impairments that may interfere with body structure/function and /or activity/participation as defined by the World Health Organization (see Fundamental Components and Guiding Principles).
Screening may result in recommendations for rescreening, comprehensive speech, language, or cognitive-communication assessment, or in a referral for other examinations or services.
Adults of all ages are screened as needed, requested, or mandated, or when other evidence suggests that they are at risk for speech, language, or cognitive-communication disorders involving body structure/function and/or activities/participation.
Standardized and nonstandardized methods are used to screen oral motor function, speech production skills, comprehension and production of spoken and written language, and cognitive aspects of communication. Services are sensitive to cultural and linguistic diversity. Screening typically focuses on body structures/functions, but may also address activities/participation, and contextual factors affecting communication.
Individuals who fail screenings are referred to speech-language pathologists for further assessment.
Setting: Screening is conducted in a clinical or natural environment conducive to eliciting a representative sample of the patient's/client's speech, language, and cognitive-communication functions and activities.
Equipment Specifications: All equipment is used and maintained in accordance with manufacturer's specifications.
Safety and Health Precautions: All services ensure the safety of the patient/client and clinician and adhere to universal health precautions (e.g., prevention of bodily injury and transmission of infectious disease). Decontamination, cleaning, disinfection, and sterilization of multiple-use equipment before reuse are carried out according to facility-specific infection control policies and procedures and according to manufacturer's instructions.
Documentation includes a statement of identifying information, screening results, and recommendations, indicating the need for rescreening, assessment, or referral.
The privacy and security of documentation are maintained in compliance with the regulations of the Health Insurance Portability and Accountability Act (HIPAA) and other state and federal laws.
Results of screening are reported to the individual and family/caregivers, as appropriate. Reports are distributed to referral source and other professionals when appropriate and with written consent.
American Speech-Language-Hearing Association. (1988). Position statement: Prevention of communication disorders. Asha, 30(3), 90.
American Speech-Language-Hearing Association. (1993). Definitions of communication disorders and variations. Asha, 35(Suppl. 10), 40-41.
World Health Organization. (2001). International classification of functioning, disability and health. Geneva, Switzerland: Author.
Swallowing screening is a pass/fail procedure to identify individuals who require a comprehensive assessment of swallowing function or a referral for other professional and/or medical services.
Screening is conducted according to the Fundamental Components and Guiding Principles.
Swallowing screening is conducted by appropriately credentialed and trained speech-language pathologists.
Swallowing screening identifies persons who are likely to have swallowing impairments related to function, activity, and/or participation as defined by the World Health Organization (see Fundamental Components and Guiding Principles). Impairments may cause pulmonary aspiration, airway obstruction, or inadequate nutrition and/or hydration
Screening may result in recommendations for rescreening or comprehensive assessment of swallowing function, or in a referral for other examinations or services.
Individuals of all ages are screened as needed, requested, or mandated or when other evidence (e.g., neurological or structural deficits) suggests that they are at risk for a swallowing disorder involving body structure/function and/or activities/participation.
Screening services are sensitive to cultural and linguistic diversity. Screening may include the following:
Interview or questionnaire that addresses swallowing function.
Observation of the signs and symptoms of oropharyngeal swallowing dysfunction.
Observation of routine or planned feeding situation, if indicated.
Formulation of appropriate recommendations, including the need for a full swallow function assessment.
Communication of results and recommendations to the team responsible for the individual's care.
Individuals who fail the screening are referred for a full swallow function assessment by a speech-language pathologist and/or other medical services as appropriate.
Setting: Screening is conducted in a clinical or natural environment conducive to obtaining valid screening results, which may include settings such as bedside, home, or hospice. Patient/client positioning and comfort, functional competencies, and environmental distractors are observed during routine or planned oral intake/feeding.
Equipment Specifications: All equipment is used and maintained in accordance with the manufacturer's specifications.
Safety and Health Precautions: All procedures ensure the safety of the patient/client and clinician and adhere to universal health precautions (e.g., prevention of bodily injury and transmission of infectious disease). Decontamination, cleaning, disinfection, and sterilization of multiple-use equipment before reuse are carried out according to facility-specific infection control policies and procedures and according to the manufacturer's instructions.
Documentation includes a statement of identifying information, screening results, and recommendations, indicating the need for rescreening, assessment, or referral.
The privacy and security of documentation are maintained in compliance with the regulations of the Health Insurance Portability and Accountability Act (HIPAA), the Family Educational Rights and Privacy Act (FERPA), and other state and federal laws.
Results of screening are reported to the individual and family/caregivers, as appropriate. Reports are distributed to referral source and other professionals when appropriate and with written consent.
American Speech-Language-Hearing Association. (2000). Guidelines for the roles and responsibilities of the school-based speech-language pathologist. Rockville, MD: Author.
American Speech-Language-Hearing Association. (2001). Roles of speech-language pathologists in swallowing and feeding disorders: Technical report. ASHA 2002 Desk Reference, 3, 181-199.
American Speech-Language-Hearing Association. (2002). Knowledge and skills for speech-language pathologists performing endoscopic assessment of swallowing. ASHA Supplement, 22, 107-112.
American Speech-Language-Hearing Association. (2002). Knowledge and skills needed by speech-language pathologists providing services to individuals with swallowing and/or feeding disorders. ASHA Supplement 22, 81-87.
American Speech-Language-Hearing Association. (2002). Roles of speech-language pathologists in swallowing and feeding disorders: Position statement. ASHA Supplement 22, 73.
American Speech-Language-Hearing Association. (2004). Guidelines for speech-language pathologists performing videofluoroscopic swallowing studies. ASHA Supplement 24, 77-92.
American Speech-Language-Hearing Association. (2004). Knowledge and skills for speech-language pathologists performing videofluoroscopic swallowing studies. ASHA Supplement 24, 178-183.
American Speech-Language-Hearing Association. (2004). Role of the speech-language pathologist in the performance and interpretation of endoscopic evaluation of swallowing: Position statement. Available from http://www.asha.org/policy.
American Speech-Language-Hearing Association. (2004). Role of the speech-language pathologist in the performance and interpretation of endoscopic evaluation of swallowing: Technical report. Available from http://www.asha.org/policy.
American Speech-Language-Hearing Association. (2004). Speech-language pathologists training and supervising other professionals in the delivery of services to individuals with swallowing and feeding disorders: Position statement. ASHA Supplement 24, 62.
American Speech-Language-Hearing Association. (2004). Speech-language pathologists training and supervising other professionals in the delivery of services to individuals with swallowing and feeding disorders: Technical report. ASHA Supplement 24, 131-134.
World Health Organization. (2001). International classification of functioning, disability and health. Geneva, Switzerland: Author.
Audiologic screening services are limited to pure-tone air conduction screening and screening tympanometry for initial identification and/or referral purposes. These are pass/fail procedures to identify individuals who require referral for further audiologic assessment or other professional and/or medical services.
Audiologic screening is conducted according to the Fundamental Components and Guiding Principles.
Audiologic screening is conducted by appropriately credentialed and trained speech-language pathologists, possibly supported by speech-language pathology assistants under appropriate supervision.
Audiologic screening identifies those persons who are likely to have hearing impairments or disorders that may interfere with body function/structure and/or activity/participation as defined by the World Health Organization (WHO) (see Fundamental Components and Guiding Principles).
Screening may result in recommendations for rescreening, or referral for comprehensive audiologic assessment or other medical examinations or services.
Audiologic screening services are provided to children or adults as needed, requested, or mandated or when other evidence suggests risk for hearing impairments affecting body structure/function, activities, or participation.
Screening for hearing impairment consists of pure tones presented via earphones at 1000, 2000, and 4000 Hz at 20 dB HL for children (ages 3–18) via conventional or conditioned play audiometry, and at 25 dB HL for adults.
Patients/clients who do not respond at any frequency in either ear are rescreened.
Patients/clients who fail the rescreen are referred to an audiologist for an audiologic evaluation.
Screening for outer and middle ear disorders in children (birth-18 years) includes visual inspection, otoscopic examination, and screening tympanometry.
Patients/clients who fail the screening are rescreened.
Patients/clients who fail the rescreening are referred for medical and/or audiologic follow-up.
Screening for hearing disability is conducted by interview, case history, and/or questionnaire.
Patients/clients who fail the screening are referred for audiologic assessment.
Screening services are sensitive to cultural and linguistic diversity.
Setting: Screening is conducted in a clinical or natural environment conducive to obtaining valid screening results. Settings for screening may include hospitals, clinics, schools, homes, or hospice facilities. Ambient noise levels may not always meet ANSI standards for pure-tone threshold testing but are sufficiently low to allow accurate screening.
Equipment Specifications: All equipment is used and maintained in accordance with the manufacturer's specifications. Electroacoustic equipment meets ANSI and manufacturer's specifications.
Safety and Health Precautions: All services ensure the safety of the patient/client and clinician and adhere to universal health precautions (e.g., prevention of bodily injury and transmission of infectious disease). Decontamination, cleaning, disinfection, and sterilization of multiple-use equipment before reuse are carried out according to facility-specific infection control policies and services and according to manufacturer's instructions.
Documentation includes a statement of identifying information, screening results, and recommendations, indicating the need for rescreening, assessment, or referral.
The privacy and security of documentation are maintained in compliance with the regulations of the Health Insurance Portability and Accountability Act (HIPAA), the Family Educational Rights and Privacy Act (FERPA), and other state and federal laws.
Results of screening are reported to the individual and family/caregivers, as appropriate. Reports are distributed to referral source and other professionals when appropriate and with written consent.
American National Standards Institute. (1987). Specifications for instruments to measure aural acoustic impedance and admittance (aural acoustic immittance). In New York: Acoustical Society of America.
American National Standards Institute. (1991). Maximum permissible ambient noise levels for audiometric test rooms. In New York: Acoustical Society of America.
American National Standards Institute. (1996). Specifications for audiometers. In New York: Acoustical Society of America.
American Speech-Language-Hearing Association. (1988). Position statement: Prevention of communication disorders. Asha, 30(3), 90.
American Speech-Language-Hearing Association. (1991). The prevention of communication disorders tutorial. Asha, 33(Suppl. 6), 15-41.
American Speech-Language-Hearing Association. (1993). Definitions of communication disorders and variations. Asha, 35(Suppl. 10), 40-41.
American Speech-Language-Hearing Association. (1997). Guidelines for audiologic screening. Rockville, MD: Author.
American Speech-Language-Hearing Association. (2001). Scope of practice in speech-language pathology. Rockville, MD: Author.
American Speech-Language-Hearing Association. (2004). Clinical practice by certificate holders in the profession in which they are not certified. ASHA Supplement 24, 39-42.
World Health Organization. (2001). International classification of functioning, disability and health. Geneva, Switzerland: Author.
Consultation is a service related to speech-language, communication, and swallowing issues, including collaborating with other professionals, family/caregivers, and patients/clients; working with individuals in business, industry, education, and other public and private agencies; engaging in program development, supervision, or evaluation activities; or providing expert testimony.
Consultation is conducted according to the Fundamental Components and Guiding Principles.
Consultation is provided by appropriately credentialed and trained speech-language pathologists.
Speech-language pathologists may provide these services individually or as members of collaborative teams that may include the individual, family/caregivers, or other relevant persons (e.g., educators, medical personnel).
Goals and expectations of consultation are variable and are negotiated between the consultant and those seeking consultation. The consultant collaborates in joint problem solving to address mutual goals. Information is sought about the perceptions and priorities of those involved in the consultation process.
Information is shared regarding communication development and processes, speech-language and communication impairments and related disorders, assessment and intervention strategies, and other issues related to the goals of the consultation.
Consultation services are provided by arrangement or upon request and address situations such as the following:
Prevention of communication disorders.
Identification of persons at risk for communication disorders.
Assessment and intervention plans and procedures and interpretation of results.
Monolingual English language speakers providing services to clients who speak languages other than English.
Environmental assessment and modification.
Equipment and material needs and/or modifications.
Program evaluation and management.
Quality assessment and improvement.
Education and advocacy.
Second opinion and/or independent educational evaluation.
Expert testimony.
Consulting activities take many forms. As appropriate to the situation, the consultant —
collaborates with others to develop mutual goals for the consultation activity;
gathers information through observations, interviews, assessments or other direct services, and through review of records and materials;
assesses the type and extent of assistance required;
makes recommendations or provides information;
provides training on communication and swallowing issues;
provides monitoring and follow-up services;
provides information to federal and state government agencies, business, and industry;
provides expert testimony regarding speech-language and communication issues.
Setting: Consultation services are offered to individuals, families, groups, and organizations in home, health care, education, business, industrial, government, and legal settings.
Equipment Specifications: All equipment is used and maintained in accordance with the manufacturer's specifications.
Safety and Health Precautions: All procedures ensure the safety of the patient/client and clinician and adhere to universal health precautions (e.g., prevention of bodily injury and transmission of infectious disease). Decontamination, cleaning, disinfection, and sterilization of multiple-use equipment before reuse are carried out according to facility-specific infection control policies and procedures and according to manufacturer's instructions.
The consulting speech-language pathologist provides written plans and/or reports as documentation of services rendered as indicated in the agreement made between the parties.
The privacy and security of documentation are maintained in compliance with the regulations of the Health Insurance Portability and Accountability Act (HIPAA), the Family Educational Rights and Privacy Act (FERPA), and other state and federal laws.
American Speech-Language-Hearing Association. (1991). A model for collaborative service delivery for students with language-learning disorders in the public schools. Asha, 33(Suppl. 5), 44-50.
American Speech-Language-Hearing Association. (1994). Professional liability and risk management for the audiology and speech-language pathology professions. Asha, 36(Suppl. 12), 25-38.
American Speech-Language-Hearing Association. (1995). Position statement and guidelines on acoustics in educational settings. Asha, 37(Suppl. 14), 15-19.
American Speech-Language-Hearing Association. (2002). A workload analysis approach for establishing speech-language caseload standards in the schools: Technical report. Rockville, MD: Author.
American Speech-Language-Hearing Association. (2003). Appropriate school facilities for students with speech-language-hearing disorders: Technical report. ASHA Supplement 23, 83-86.
American Speech-Language-Hearing Association. (2003). Knowledge and skills in business practices needed by speech-language pathologists in health care settings. ASHA Supplement, 23, 87-92.
American Speech-Language-Hearing Association. (2004). Knowledge and skills in business practices for speech-language pathologists who are managers and leaders in health care organizations. ASHA Supplement 24, 146-151.
World Health Organization. (2001). International classification of functioning, disability and health. Geneva, Switzerland: Author.
Counseling provides individuals, families/caregivers, and other relevant persons with information and support about communication and/or swallowing disorders to develop problem-solving strategies that enhance the (re)habilitation process.
Counseling is conducted according to the Fundamental Components and Guiding Principles.
Counseling is conducted by appropriately credentialed and trained speech-language pathologists.
Speech-language pathologists may provide these services individually or as members of collaborative teams that may include the individual, family/caregivers, and other relevant persons (e.g., educators, psychologists, social workers, physicians).
Consistent with the World Health Organization (WHO) framework, counseling is designed to—
assist individuals to develop appropriate goals related to a communication or swallowing disorder that capitalize on strengths and address weaknesses related to underlying structures and functions that affect communication/swallowing;
facilitate the individual's activities and participation by assisting the person to increase autonomy, self-direction, and responsibility for acquiring and utilizing new skills and strategies that are related to their goals to communicate or swallow more effectively;
assist individuals in understanding how to modify contextual factors to reduce barriers and enhance facilitators of successful communication/swallowing and participation.
Counseling is expected to result in improved abilities, functioning, participation, and contextual facilitators. Counseling also may result in recommendations for speech-language or swallowing reassessment or follow-up, or in a referral for other services.
Counseling is prompted by referral and/or by the results of a communication or swallowing assessment. Individuals of all ages may receive counseling as part of intervention and/or consultation services when their ability to communicate or swallow effectively is impaired and when there is a reasonable expectation of benefit to the individual in body structure/function and/or activity/participation. Counseling may be warranted even if the prognosis for improved body structure/function is limited.
Counseling involves providing timely information and guidance to patients/clients, families/caregivers, and other relevant persons about the nature of communication or swallowing disorders, the course of intervention, ways to enhance outcomes, coping with disorders, and prognosis. Services are sensitive to cultural and linguistic diversity.
Depending on assessment results, counseling addresses the following:
Assessment of counseling needs.
Provision of information.
Use of strategies to modify behavior and/or the individual's environment.
Development of coping mechanisms and systems for emotional support.
Development and coordination of individual and family self-help and support groups.
Speech-language pathologists are responsible for ensuring that individuals, families/caregivers, and other relevant persons receive counseling about communication and swallowing issues. Referrals to and consultation with mental health professionals may be an integral component of counseling.
Counseling extends long enough to accomplish stated objectives/predicted outcomes. The counseling period does not continue past the point at which there is no longer any expectation for further benefit.
Setting: Counseling is conducted in clinical and educational settings and other natural environments that are conducive to individual and family comfort, confidentiality, and uninterrupted privacy. Settings are selected with consideration for the social, academic, and/or vocational activities that are relevant to or desired by the individual. In any setting, counseling addresses the personal and environmental factors that are barriers to or facilitators of the patient's/client's communication or swallowing.
Equipment Specifications: All equipment is used and maintained in accordance with the manufacturer's specifications.
Safety and Health Precautions: All services ensure the safety of the patient/client and clinician and adhere to universal health precautions (e.g., prevention of bodily injury and transmission of infectious disease). Decontamination, cleaning, disinfection, and sterilization of multiple-use equipment before reuse are carried out according to facility-specific infection control policies and services and according to manufacturer's instructions.
Documentation includes the following:
Written record of the dates, length, and type of counseling services that were provided.
Progress toward stated goals, updated prognosis, and specific recommendations.
Evaluation of counseling outcomes and effectiveness within the WHO framework of body structures/functions, activities/participation, and contextual factors.
The privacy and security of documentation are maintained in compliance with the regulations of the Health Insurance Portability and Accountability Act (HIPAA), Family Education Rights and Privacy Act (FERPA), and other state and federal laws.
American Speech-Language-Hearing Association. (2000). Guidelines for the roles and responsibilities of the school-based speech-language pathologist. In Rockville, MD: Author.
American Speech-Language-Hearing Association. (2004). Knowledge and skills needed by speech-language pathologists providing services to infants and families in the NICU environment. ASHA Supplement 24, 159-165.
American Speech-Language-Hearing Association. (2004). Roles of speech-language pathologists in the neonatal intensive care unit: Guidelines. Available from http://www.asha.org/policy.
American Speech-Language-Hearing Association. (2004). Roles of speech-language pathologists in the neonatal intensive care unit: Position statement. ASHA Supplement 24, 60-61.
American Speech-Language-Hearing Association. (2004). Roles of speech-language pathologists in the neonatal intensive care unit: Technical report. ASHA Supplement 24, 121-130.
World Health Organization. (2001). International classification of functioning, disability and health. Geneva, Switzerland: Author.
Follow-up procedures are used to complete or supplement an assessment, monitor progress during intervention, and/or determine status after screening, assessment, intervention, or discharge.
Follow-up procedures are conducted according to the Fundamental Components and Guiding Principles.
Follow-up procedures are conducted by appropriately credentialed and trained speech-language pathologists, possibly supported by speech-language pathology assistants under appropriate supervision.
Follow-up procedures complete an assessment and determine reassessment needs.
Follow-up procedures determine efficacy of intervention, functional outcomes, maintenance of level of function achieved at the end of intervention, and appropriateness of clinical decisions and clinical recommendations.
Follow-up procedures may result in recommendations for continued or repeated assessment and/or intervention, referral for other examinations or services, dismissal from services, or readmission to services.
Follow-up services are provided to individuals of all ages at a predetermined time following screening, assessment, or intervention, and as required by federal, state, or local regulations.
Standardized and nonstandardized methods are used to determine the individual's current status including body structures/functions, activities/participation, contextual factors affecting communication and swallowing, and level of satisfaction with services consistent with the World Health Organization (WHO) framework.
Follow-up procedures are conducted either in person (e.g., interview, reassessment) or indirectly (e.g., phone or mail surveys), and involve the patient/client, family/caregivers, professionals, and/or others associated with the individual. Follow-up procedures are sensitive to cultural and linguistic diversity.
Services include the following:
Supplemental evaluations.
Re-evaluations and rechecks.
Telephone contacts with patients/clients and/or referral agencies.
Verbal or written consultation with other professionals to monitor a patient's/client's functional communication or swallowing status and contextual factors.
Materials and approaches are appropriate to the individual's chronological and developmental ages, medical status, physical and sensory abilities, education, vocation, cognitive status, and cultural, socioeconomic, and linguistic backgrounds.
Setting: Follow-up procedures are conducted in a clinical or educational setting, or other natural environment. Selection of settings for follow-up are based on the goals of assessment with consideration of the WHO framework.
Equipment Specifications: All equipment is used and maintained in accordance with the manufacturer's specifications.
Safety Precautions: All services ensure the safety of the patient/client and clinician and adhere to universal health precautions (e.g., prevention of bodily injury and transmission of infectious disease). Decontamination, cleaning, disinfection, and sterilization of multiple-use equipment before reuse are carried out according to facility-specific infection control policies and procedures and manufacturer's instructions.
Documentation includes a statement of pertinent background information, results, progress, and recommendations, indicating the need for reassessment, continued or additional intervention, or referral.
The privacy and security of documentation are maintained in compliance with the regulations of the Health Insurance Portability and Accountability Act (HIPAA), Family Education Right to Privacy Act (FERPA), and other state and federal laws.
Results of the follow-up are reported to the individual and family/caregivers, as appropriate. Reports are distributed to referral source and other professionals when appropriate and with written consent.
American Speech-Language-Hearing Association. (1988). Position statement: Prevention of communication disorders. Asha, 30(3), 90.
American Speech-Language-Hearing Association. (1993). Definitions of communication disorders and variations. Asha, 35(Suppl. 10), 40-41.
World Health Organization. (2001). International classification of functioning, disability and health. Geneva, Switzerland: Author.
Prevention services are designed to avoid communication or swallowing disorders, minimize their effects and sequelae, and facilitate normal development.
Prevention is conducted according to the Fundamental Components and Guiding Principles.
Prevention services are conducted by appropriately credentialed and trained speech-language pathologists, possibly supported by speech-language pathology assistants under appropriate supervision.
Speech-language pathologists may provide these services individually or as members of collaborative teams that may include the individual, family/caregivers, and other relevant persons (e.g., educators, medical personnel).
Consistent with the World Health Organization (WHO) framework, prevention is designed to—
inhibit or delay the onset of a communication or swallowing disorder by capitalizing on strengths, addressing weaknesses related to underlying structures and functions that may interfere with communication/swallowing, and facilitating normal development;
minimize impact of risk factors, associated conditions, and sequelae to facilitate individuals' activities and level of participation;
reduce exposure to contextual factors that may interfere with successful communication/swallowing activities and participation and provide appropriate accommodations and other supports, as well as training in how to use them.
Prevention is expected to result in a reduced risk for communication or swallowing disorders and their sequelae. Prevention also may result in recommendations for speech-language and communication or swallowing reassessment or follow-up, or in a referral for other services.
Prevention is prompted by referral, the results of a speech-language assessment, or other indications of need. Individuals of all ages may receive prevention services when they are deemed to be at risk for impaired ability to communicate effectively or swallow safely and when there is a reasonable expectation of benefit to the individual in body structure/function and/or activity/participation. Prevention services that enhance activity and participation through modification of contextual factors may be warranted even if the prognosis for improved body structure/function is limited.
Prevention involves providing information and guidance to patients/clients, families, other significant persons, or target groups about the risk for or ramifications of a communication or swallowing disorder with sensitivity to cultural and linguistic diversity.
Depending on the nature of the risk, prevention may involve—
identifying and contacting target groups;
establishing professional relationships;
providing consultation and educational strategies:
Consultation may be provided to natural support systems, such as the family, or to direct service personnel, organizations, or policymaking groups.
Education may provide general information about communication or swallowing processes, disorders, and intervention; specific information to help target groups identify and/or eliminate risk factors for the onset, development, or maintenance of a communication or swallowing disorder; or may improve target groups' ability to cope with communication disorders.
Prevention services extend long enough to accomplish stated objectives/predicted outcomes.
Setting: Prevention services are conducted in a clinical or educational setting and/or other natural environments that are selected on the basis of prevention goals and in consideration of the social, academic and/or vocational activities that are relevant to or desired by individuals, families, groups, communities, or organizations. In any setting, prevention addresses the personal, cultural, and environmental factors that increase the risk of a communication or swallowing disorder.
Equipment Specifications: All equipment is used and maintained in accordance with the manufacturer's specifications.
Safety Precautions: All prevention services ensure the safety of the patient/client and clinician and adhere to universal health precautions (e.g., prevention of bodily injury and transmission of infectious disease). Decontamination, cleaning, disinfection, and sterilization of multiple-use equipment before reuse are carried out according to facility-specific infection control policies and services and according to manufacturer's instructions.
Documentation includes the following:
Written record of the dates, length, and type of prevention services that were provided.
Progress toward stated goals, updated prognosis, and specific recommendations.
Evaluation of prevention outcomes and effectiveness within the WHO framework of body structures/functions, activities/participation, and contextual factors.
The privacy and security of documentation are maintained in compliance with the regulations of the Health Insurance Portability and Accountability Act (HIPAA), Family Educational Rights and Privacy Act (FERPA), and other state and federal laws.
American Speech-Language-Hearing Association. (1988). Prevention of communication disorders. Asha, 30(3), 90.
American Speech-Language-Hearing Association. (1991). The prevention of communication disorders tutorial. Asha, 33(Suppl. 6), 15-41.
American Speech-Language-Hearing Association. (2000). Guidelines for the roles and responsibility of school-based speech-language pathologists. In Rockville, MD: Author.
World Health Organization. (2001). International classification of functioning, disability and health. Geneva, Switzerland: Author.
Elective communication modification services are for individuals who do not have a communication disorder but who wish to receive assistance from a speech-language pathologist to enhance their communication effectiveness. Communication modification includes instruction in public speaking, accent modification, and interpersonal communication skills.
Communication modification is conducted according to the Fundamental Components and Guiding Principles.
Communication modification for adults is conducted by appropriately credentialed and trained speech-language pathologists, possibly supported by speech-language pathology assistants under appropriate supervision.
Speech-language pathologists may provide these services as members of collaborative teams that may include the individual, family/caregivers, and other relevant persons.
Consistent with the World Health Organization (WHO) framework, communication modification is designed to—
capitalize on strengths and address weaknesses related to functions that affect communication;
facilitate the individual's activities and participation by assisting the person to acquire new skills and strategies;
modify contextual factors that serve as barriers and enhance facilitators of successful communication and participation.
Communication modification is expected to result in reduced contextual barriers, improved abilities and contextual facilitators, and measurably enhanced functioning and participation. Communication modification services also may result in recommendations for reassessment or follow-up, or in a referral for other services.
Communication modification is prompted by referral or upon request, including self-referral. Individuals of all ages may receive intervention and/or consultation services when there is an identified or perceived reduction in the ability to communicate effectively, and when there is a reasonable expectation of benefit to the individual in body structure/function and/or activity/participation.
Interventions that enhance activity and participation through modification of contextual factors may be warranted even if the prognosis for improved body structure/function is limited.
Communication modification services involve information and guidance to patients/clients, families, and other significant persons about communication, communication effectiveness, and the course of services.
Communication modification services address the complexities of communication effectiveness in a manner that is sensitive to cultural and linguistic diversity.
Depending on assessment results, communication modification may address the following:
Knowledge and use of verbal and nonverbal pragmatic rules of communication in varied communication situations.
Knowledge and application of phonological and prosodic differences.
Use of effective listening skills.
Knowledge of cultural influences on communication.
Increased ability to use speech and language skills within academic, vocational, and social contexts.
Analysis of the cognitive and communication demands of relevant social, academic, and/or vocational tasks and contexts, and subsequent appropriate strategies for modifying communication.
Voice care and techniques for modulating intensity, pitch, and quality without inducing strain.
Development of self-assessment and monitoring techniques.
Development of plans, including referral, for problems such as hearing difficulties and emotional disturbance.
Communication modification services extend long enough to accomplish stated objectives/predicted outcomes and end when there is no longer any expectation for further benefit. Clinicians provide patients/clients and their families/caregivers with an estimate of the duration of communication modification services.
Setting: Communication modification services may be conducted in a variety of settings and are selected on the basis of intervention goals and in consideration of the social, academic, and/or vocational activities that are relevant to or desired by the individual. In any setting, communication modification addresses the personal and environmental factors that are barriers to or facilitators of the patient's/client's communication function. There is a plan to generalize and maintain communication gains and to increase participation in relevant settings and activities.
Equipment Specifications: All equipment will be used and maintained in accordance with the manufacturer's specifications.
Safety and Health Precautions: All services ensure the safety of the patient/client and clinician and adhere to universal health precautions (e.g., prevention of bodily injury and transmission of infectious disease). Decontamination, cleaning, disinfection, and sterilization of multiple-use equipment before reuse are carried out according to facility-specific infection control policies and services and manufacturer's instructions.
Documentation includes the following:
Indication that the services were elective.
Written records of the dates, length, and type of services that were provided.
Evaluation of communication modification outcomes and effectiveness as applied to activities, participation, and contextual factors.
Progress toward stated goals.
Specific recommendations.
The privacy and security of documentation are maintained in compliance with the regulations of the Health Insurance Portability and Accountability Act (HIPAA) the Family Education Rights and Privacy Act (FERPA), and other state and federal laws.
American Speech-Language-Hearing Association. (1983). Social dialects and implications of the position on social dialects. Asha, 25, 23-27.
American Speech-Language-Hearing Association. (1988, March). Prevention of communication disorders: Position Statement. Asha, 30, 90.
American Speech-Language-Hearing Association. (1993). Definitions of communication disorders and variations. Asha, 35(Suppl. 10), 40-41.
American Speech-Language-Hearing Association. (2003). Technical report: American English dialects. ASHA Supplement 23, 45-46.
American Speech-Language-Hearing Association. (2004). Knowledge and skills needed by speech-language pathologists and audiologists to provide culturally and linguistically appropriate services. ASHA Supplement 24, 152-158.
American Speech-Language-Hearing Association Joint Subcommittee of the Executive Board on English Language Proficiency. (1998). Students and professionals who speak English with accents and nonstandard dialects: Issues and recommendations. Technical report. ASHA, 40(Suppl. 18), 28-31.
World Health Organization. (2001). International classification of functioning, disability and health. Geneva, Switzerland: Author.
Comprehensive speech-language assessment addresses speech, language, cognitive-communication and/or swallowing function (strengths and weaknesses) in children and adults, including identification of impairments, associated activity and participation limitations, and context barriers and facilitators.
Comprehensive speech-language assessment is conducted according to the Fundamental Components and Guiding Principles.
Comprehensive speech-language assessments are conducted by appropriately credentialed and trained speech-language pathologists.
Speech-language pathologists may perform these assessments individually or as members of collaborative teams that may include the individual, family/caregivers, and other relevant persons (e.g., educators and medical personnel).
Consistent with the World Health Organization (WHO) framework, assessment is conducted to identify and describe —
underlying strengths and weaknesses related to speech, language, cognitive and/or swallowing factors that affect communication and swallowing performance;
effects of speech, language, cognitive-communication and/or swallowing impairments on the individual's activities (capacity and performance in contexts) and participation;
contextual factors that serve as barriers to or facilitators of successful communication and swallowing and participation for individuals with speech, language, cognitive-communication and/or swallowing impairments.
Assessment may result in the following:
Diagnosis of a speech, language, cognitive-communication and/or swallowing disorder.
Clinical description of the characteristics of speech, language, cognitive-communication and/or swallowing impairments.
Identification of a communication difference, possibly co-occurring with a speech, language, cognitive-communication and/or swallowing disorder.
Prognosis for change (in the individual or relevant contexts).
Recommendations for intervention and support.
Identification of the effectiveness of intervention and supports.
Referral for other assessments or services.
Assessment services are provided to individuals of all ages as needed, requested, or mandated or when other evidence suggests that they have speech, language, cognitive-communication and/or swallowing impairments affecting body structure/function and/or activities/participation.
Assessment is prompted by referral, by the individual's medical status, educational performance, or by failing a speech-language or swallowing screening that is sensitive to cultural and linguistic diversity.
Comprehensive assessment is sensitive to cultural and linguistic diversity and addresses the components within the WHO's International Classification of Functioning, Disability and Health (2001) framework including body structures/functions, activities/participation, and contextual factors.
Assessment may be static (i.e., using procedures designed to describe current levels of functioning within relevant domains) and/or dynamic (i.e., using hypothesis testing procedures to identify potentially successful intervention and support procedures) and includes the following:
Relevant case history, including medical status, education, vocation, and socioeconomic, cultural, and linguistic backgrounds.
Review of auditory, visual, motor, and cognitive status.
Patient/client and family interview.
Standardized and/or nonstandardized measures of specific aspects of speech, spok