What are the Indications for a Referral to Speech Therapy?

Patient Presentation
A 40 month-old male came to clinic for his health maintenance examination. His parents had no concerns.
During the examination, the experienced physician noted that it was extremely difficult to understand the boy’s words. The child could follow simple instructions, and he made lots of sounds that had good tone and inflection like a sentence. He also took turns in the conversation and used non-verbal communication with facial expressions and gesturing.
His words did not appear consistent in that either initial or ending sounds were dropped, nor were particular sounds consistently difficult to understand. The physician estimated that she could understand only 30-40% of what he said. The parents also could not translate his words, but said they just understood what he wanted.
The boy’s uncle that he doesn’t see very often had noted to the parents previously that he had a hard time understanding the boy.
The boy’s aunt babysits him and has said that sometimes she has a hard time understanding him.
The past medical history reveals 2 episodes of otitis media.
The family history is negative for speech or hearing problems, and developmental or learning problems.
The review of systems is negative.
The pertinent physical exam reveals a happy, developmentally-appropriate male with growth parameters in the 25%. He has grossly normal hearing. His examination is otherwise negative.
The diagnosis of probable speech delay was made and the patient was referred for a hearing test and speech and language evaluation. In the meantime, the family was instructed to have a language-rich environment with lots of conversation about daily activities. They were to encourage him to use his words more than gestures, but also not to force him to use his words and become frustrated.

Speech and language acquisition and use is a complex process. Speech production by one person must be heard, processesd and then responded to by another person.
Speech and language problems are grossly categorized as receptive problems (i.e. receiving the information) or expressive problems (i.e. processing and responding to the information).
In very simplistic terms, there can therefore be a problem with the auditory system, the central nervous system, or the oral motor system.
In reality, many more systems (e.g. respiratory for speech production) are involved and each system must coordinate with the others to have appropriate speech and language acquisition and use.

Developmentally, children learn to make sounds and later words and phrases in a fairly characteristic developmental pattern. Vowels sounds first (i.e. o, a), then consonant sounds next (e.g. m, b,), with individual vowel consonant syllables appearing (e.g. ma, ba), followed by vowel-consonant syllable repetitions (e.g. ma-ma-ma-ma), then single words, and finally phrases/sentences.
A general rule is that for each year of age a child should add 1 word to the number of words they have in the sentence they are making (i.e. 1 word sentence at age 2, 2 word sentence at age 2, 3 word sentence at age 3, etc.) They also should gain ~25% more intelligibility with each year (i.e. 25% of their speech is intelligible at age 1, 50% is intelligible at age 2, 75% intelligible at age 3, etc.).

Children can have normal disfluencies such as repeating initial sounds (e.g. li-li-like this) or whole words (e.g. this-this-this is an animal) especially when they are excited, tired, or talking to inattentive listeners. They also have occasional pauses, hesitations or fill in sounds (e.g. um or uh). Disfluencies should not be consistently present after the age of 7 years.

Screening tests can be administered in the health providers office including the Denver Developmental Screening Test, Early Language Milestone and CLAM (Child Language Ability Measures).

Learning Point
Indications for referral to a speech and language pathologist includes:

  • Parental concerns, especially if there is a family history of speech, hearing, or other developmental problems
  • Other caregiver concerns, particularly if more than one caregiver is concerned
  • Formal screening tests below age norms, particularly if the child has other developmental delays or if both expressive and receptive language appear affected
  • Speech sounds are more than 1 year late in appearing by the normal developmental sequence
  • Child is frustrated, has poor self-esteem or is being teased/shunned by other children or adults because of the possible speech and language problem
  • No speech production or does not follow simple directions by age 18 months
  • Speech is frequently unintelligible after 2.5 years
  • No sentences by age 3 years
  • Child is distorting, omitting or substituting any speech sound after age 7 years
  • There are unusual confusions, or reversals in connected speech
  • Many omissions of initial consonant sounds at any age (e.g. “ish” for fish, ‘owl’ for bowl)
  • Child uses mostly vowel sounds
  • Word endings are consistently dropped
  • Child’s speech has abnormal rhythm, rate or inflection or is noticeably non-fluent
  • Sentence structure is noticeably faulty
  • Voice is monotone, extremely loud, largely inaudible or of poor quality
  • Voice pitch is not appropriate to child’s age or sex
  • Voice is noticeably hypernasal or has lack of nasal resonance

Questions for Further Discussion
1. Why should a hearing test be performed if a speech and language problem is suspected?
2. How do hearing impaired children present?
3. How to language impaired children present?

Related Cases

To Learn More
To view pediatric review articles on this topic from the past year check PubMed.

Information prescriptions for patients can be found at MEDLINEplus for this topic: Speech and Communication Disorders.

To view current news articles on this topic check Google News.

Merrifield B. “Common Speech Problems – What is Normal?” Lecture notes. 1997.

Grizzle KL, Simms MD. Early language development and language learning disabilities. Pediatr Rev. 2005 Aug;26(8):274-83. Available from the Internet at: http://pedsinreview.aappublications.org/cgi/content/full/26/8/274 (cited 7/19/06).

ACGME Competencies Highlighted by Case

  • Patient Care
    1. When interacting with patients and their families, the health care professional communicates effecively and demonstrates caring and respectful behaviors.
    2. Essential and accurate information about the patients is gathered.
    3. Informed decisions about diagnostic and therapeutic interventions based on patient information and preferences, up-to-date scientific evidence, and clinical judgment is made.
    4. Patient management plans are developed and carried out.
    5. Patients and their families are counseled and educated.
    8. Health care services aimed at preventing health problems or maintaining health are provided.
    9. Patient-focused care is provided by working with health care professionals, including those from other disciplines.

  • Medical Knowledge
    10. An investigatory and analytic thinking approach to the clinical situation is demonstrated.
    11. Basic and clinically supportive sciences appropriate to their discipline are known and applied.

  • Practice Based Learning and Improvement
    13. Information about other populations of patients, especially the larger population from which this patient is drawn, is obtained and used.

  • Systems Based Practice
    25. Quality patient care and assisting patients in dealing with system complexities is advocated.

    Donna M. D’Alessandro, MD
    Associate Professor of Pediatrics, Children’s Hospital of Iowa

    Sarah A. Michaels, MA, CCC-SLP
    Speech and Language Pathologist

    August 14, 2006