When to Refer

Guidelines on When to Refer for Speech-Language Pathology Services

A child may benefit from speech-language pathology services if he cannot communicate as well as other children at the same age, or if he has difficulty with feeding or swallowing. Speech-language pathology services should be considered if a child demonstrates any of the following symptoms:

A child with a language disorder may have difficulty understanding language, following directions, or choosing appropriate words and combining them correctly in sentences. Language disorders can affect a child’s ability to interact with others and to learn. Some characteristics of a language disorder at different ages include:

  • 4 months: Poor eye contact; inattentive to the speech of others
  • 6-8 months: Lack of gestures
  • 12 months: Difficulty understanding speech or following simple directions
  • 16-18 months: No words, or a limited vocabulary
  • 24-26 months: Lack of ability to combine words for short sentences
  • 3 years: Echoes in words or phrases or many errors in sentences
  • 3-4 years: Lack of ability to retell stories or talk about past events
  • 6 years: Trouble with attention, memorization of facts, learning or reading

A child with an articulation (speech sound) disorder may have difficulty producing individual sounds. As a result, the child may substitute an easy sound for a harder one (e.g., “tun” for sun), omit sounds (e.g., “ool” for school) or distort sounds (e.g., “shlun” for sun). In some cases (e.g., apraxia of speech), the child may have difficulty combining the movements of speech sounds in sequences, as required for words and sentences. Articulation errors often make speech very hard to understand. Some characteristics of an articulation disorder at different ages include:

  • 8-9 months: No babbling in a repetitive manner
  • 18 months: Use of vowels primarily or only a few consonants
  • 3 years: Leaving out consonants or unclear speech
  • 4 years: Distorted speech that is often hard to understand
  • 6 years: No production of some speech sounds

A child with a fluency disorder (stuttering) has frequent abnormal disruptions in the flow of speech. Characteristics of a fluency disorder include:

  • Involuntary repetitions, hesitations, prolongations, blocks or disruptions during speech
  • Tension during speech or abnormal movements such as jerking or forceful eye blinking
  • Refusal to talk to strangers due to a fear of stuttering
  • Embarrassment during speaking

A child with a voice disorder has either abnormal vocal cord structure or abnormal function. Characteristics of a voice disorder include:

  • A chronically hoarse, harsh, breathy or raspy voice quality
  • An inappropriate vocal pitch for the child’s age or sex
  • Frequent pitch breaks
  • A voice that is consistently too soft

A child with a resonance disorder will have either velopharyngeal dysfunction (a problem with the valve that closes off the nose from the mouth during speech) or blockage in the nose, throat or back of the mouth. Types of resonance disorders include:

  • Hypernasality due to too much sound in the nasal cavity during speech
  • Hyponasality due to a blockage in the nasal cavity
  • Cul-de-sac resonance due to blockage in one or more areas of the vocal tract

A child with a feeding or swallowing disorder may have one or more of the following signs or symptoms:

  • Difficulty swallowing liquids or solids
  • Difficulty sucking or drinking from a cup
  • Difficulty taking foods from a spoon or chewing foods
  • Avoidance of certain types of foods or certain food textures
  • Gagging, choking or coughing during feeding

Contact Us

Speech Pathology at Cincinnati Children's.
For more information about the Division of Speech Pathology, call 513-636-4341 or email speech.pathology@cchmc.org. Physicians may fax referrals to 513-803-1111. Contact Us