American Speech-Language-Hearing Association
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Speech Referral Guidelines for Pediatrics

Most Common Etiologies

  • Cerebral palsy
  • Craniofacial disorders (e.g., cleft lip/palate)
  • Functional articulation and/or phonological disorders

Potential Consequences/Impact of Speech Impairment Can Include

  • Difficulty expressing need or routine information intelligibly
  • Difficulty communicating intelligibly in order to function at level of independence expected for age
  • Difficulty expressing feelings intelligibly; may be at risk for frustration or depression
  • Difficulty engaging successfully in social and/or classroom situations that require intelligible speech
  • Difficulty achieving adequate intelligible speech to reach educational potential
  • At risk for personal injury due to difficulty communicating intelligibly about a dangerous situation or calling for help

Behaviors that should trigger an SLP referral

By age 3 years cannot:

  • be understood by family and/or caregivers
  • correctly produce vowels and such sounds as p, b, m, w in words
  • repeat when not understood without becoming frustrated

By age 4 years cannot:

  • be understood by individuals with whom they do not associate regularly
  • be understood by family and/or caregivers
  • correctly produce t, d, k, g, f
  • be asked to repeat without becoming sensitive

By age 5 years cannot:

  • be understood in all situations by most listeners
  • correctly produce most speech sounds
  • be asked to repeat without exhibiting frustration

Disturbance in neuromuscular control causes difficulty learning to produce sounds appropriately

  • speech is usually slurred; difficulty controlling respiration for speech; abnormal loudness, rhythm, or vocal quality
  • exhibits difficulty learning sounds to form words; may sound nasal, strangled and/or breathy
  • exhibits frustration and/or avoidance of speech due to extreme difficulty forming sounds or difficulty being understood

Disturbance in programming, positioning, and sequencing of muscular movements

  • sound errors are prevalent but variable (i.e., "dog" could be produced "dog," "tog," "gog," "god" by same child)
  • varies from rarely being able to produce sounds to ongoing speech that is rarely understood, or speech that is usually understood with frequent sound errors
  • unaware of sound variations or exhibits varying degrees of frustration and/or anxiety regarding inability to "control speech"

Disturbance in performing voluntary movements with mouth and vocal mechanism

  • cannot produce movements for sound production or sounds are produced without voice (whispered speech)
  • varies from inability to produce any words to extreme difficulty being understood
  • exhibits frustration and/or avoidance of speech due to difficulties

Deafness/severe hearing loss causes severe prosodic disturbances in intonation, duration, and rhythm in addition to sound errors

  • produces no meaningful words or sounds understood only by family
  • speaks loudly in high pitched voice with frequent distortion, omission, and substitution of sounds

Autism, emotional disturbance, and/or mental retardation may cause very unusual prosodic variations

  • intonation and/or rhythm of connected speech may sound abnormal
  • volume may be consistently or intermittently too loud or too soft

Deviation in structure of speech mechanism

  • difficulty producing specific sounds and intelligible speech
  • exhibits frustration and/or avoidance of speech
  • speech has excessive nasality

Difficulty in hearing and/or inability to differentiate between sounds inhibit child's ability to detect and correct error sounds; usually unaware of errors

Intelligibility and sound production are compromised when nasal passages, nasopharynx, and larynx are bypassed due to tracheostomy/ventilator dependence

Exhibits sudden decrease in speech intelligibility

  • ranges from slurred, generally intelligible speech to total absence of speech, or totally unintelligible speech
  • awareness ranges from extremely aware to totally unaware of sound errors

Exhibits decline in ability to be understood by family, friends, and/or caregivers in the expression of basic needs, preferences, and feelings

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