QUESTIONS

[Link] conditions that you would refer a patient for speech therapy.

2. Discuss degrees of ear deafness that would require hearing aids

[Link] conditions that you would refer a patient for speech therapy.
Speech is a complex function that involves coordination between the brain, cranial nerves,
respiratory system, and articulatory structures such as the tongue, lips, and larynx. Any
disruption along this pathway can affect a person’s ability to communicate effectively. Speech
therapy therefore plays a crucial role in the assessment and rehabilitation of individuals with
speech, language, and swallowing difficulties.

In clinical practice, patients are referred for speech therapy when there is evidence of impaired
communication, whether due to developmental disorders, neurological conditions, structural
abnormalities, or acquired injuries. Early identification and referral are important because
untreated speech and language problems can significantly affect social interaction, academic
performance, and overall quality of life.

Neonatal and Infant Referral (0–2 years)

Neonatal Feeding/Swallowing:
Infants with NICU stays or risk factors (prematurity, low birth weight, hyperbilirubinemia, or
craniofacial anomalies) who exhibit poor feeding (weak suck, choking, apnea during feeds) or
suspected aspiration should be screened by an SLP. ASHA NICU guidelines recommend
immediate referral if any feeding concern is present (e.g. choking, excessive oral secretions, or
failure to thrive). Newborns who fail universal hearing screening or have risk indicators (family
history, NICU >5 days, ototoxic meds) must have audiologic evaluation by 3 months and ENT/SLP
involvement.

Preverbal Milestones:
Lack of babbling by 8–9 months, absence of gesturing (pointing, waving) or no response to
name by 12 months are red flags for hearing or communication delay. Pediatricians should refer
infants with motor speech signs (jaw/tongue movements limited, drooling) or parental concern
about hearing/speech by 12–18 mo. The language development guidelines suggest referral if a
child has fewer than 10 words by 18 months or no two-word phrases by 24 mo. Regression of
any communication skill also warrants immediate SLP evaluation (often associated with ASD or
neurologic injury)
Hearing-Related Delays:
Infants with identified hearing loss or risk of deafness should be managed by audiology and SLP
in tandem. All children with bilateral permanent hearing impairment benefit from early
amplification (hearing aids by 3–6 months) to support language. Monitor speech development
closely in any child with hearing loss, and refer to SLP for auditory-verbal therapy if
speech/language milestones lag.

Pediatric Speech/Language Disorders (2–18 years)

Speech Sound Disorders:
Children with articulation/phonology issues beyond expected ages should be referred. For
example, no repetitive babbling by 9 months, only a few consonants by 18 months, or speech
that is unintelligible to strangers by age 3–4 are referral criteria. Persistent substitutions or
distortions (e.g. lisps) beyond age 5–6 also merit evaluation. Childhood Apraxia of Speech
(CAS) is suspected when a child shows inconsistent errors on repeated attempts, groping
movements, or reduced intonation – these cases need prompt SLP assessment (though specific
CAS criteria are not formalized here).

Language Disorders:
Delays in expressive or receptive language (vocabulary, grammar, comprehension) trigger
referral. Cincinnati Children’s guidelines note concerns such as limited gestures by 12 months,
no words by 16–18 months, and failure to use multi-word utterances by age 2. Red flags include
frequent misunderstanding of simple commands, or language skills falling well behind age
peers. Speech-language evaluation is also warranted for specific disorders (e.g. Specific
Language Impairment or Learning Disabilities) identified in school-aged children.

Stuttering (Fluency) Disorders:

Significant dysfluency (stuttering) lasting >6 months, with tension or secondary behaviors (eye
blinking, grimacing) and onset before 7 years should be evaluated. Early referral is advised if
stuttering appears severe or if parents express concern, as early intervention can improve
outcomes. (A family history of persistence or increases anxiety as a red flag, although not
systematically defined here).

Voice Disorders:
Pediatric hoarseness lasting more than a few weeks (e.g. vocal strain, nodules from screaming,
or congenital laryngeal anomalies) should prompt referral. Cincinnati’s checklist lists chronically
hoarse, breathy, or high/low-pitched voice as an indicator. Velopharyngeal or resonance
problems (hypernasal speech) – often due to cleft palate or submucous cleft – are also SLP/ENT
concerns. Referral is recommended if speech sounds “nasal” or if a child has structural
anomalies of the palate.

Feeding and Swallowing (Pediatric Dysphagia):

Difficulty coordinating suck/swallow (feeding tube dependence, extended feeding time, poor
weight gain) requires neonatal SLP input. Older infants or toddlers with choking, coughing, or
recurrent pneumonias during feeding should see an SLP for dysphagia assessment. Social or
behavioral feeding issues in ASD (e.g. very limited diet due to texture aversions) also fall under
SLP care.

Autism Spectrum Disorder (ASD):

Early social-communication delays (poor eye contact, lack of joint attention, limited gestures)
often herald ASD. ASHA notes SLPs “play a central role” in screening and managing ASD-related
communication deficits. Any child suspected of ASD with language/social delays should be
referred to SLP as part of a multidisciplinary evaluation. (Notably, the USPSTF reports that
speech delay is the most common early parental concern in ASD.)

Hearing Impairment:
Children identified with even mild bilateral hearing loss should receive SLP support, since they
are at high risk for language delay. Referral to SLP (often through an auditory-verbal therapy
program) is indicated alongside audiologic management

Adult and Geriatric Referral

Neurologic Injuries:
All stroke survivors should be screened immediately for dysphagia; NICE recommends a bedside
swallow screen for every acute stroke patient, with any positive result leading to SLP referral.
Early dysphagia screening by an SLP or trained professional is advised. Stroke-induced aphasia,
dysarthria (motor speech), and cognitive-communication deficits require SLP therapy. For
example, guidelines strongly recommend speech therapy for aphasia (Level A evidence).
Traumatic Brain Injury (TBI) in adults similarly warrants SLP assessment for language, cognition,
voice, and swallowing problems. (ASHA notes that SLPs screen TBI patients for “hearing, speech,
language, cognitive-communication, and swallowing difficulties”.)

Neurodegenerative Diseases:
Progressive conditions (e.g. dementia, Parkinson’s, ALS) often impair communication or
swallowing. Any older adult with new difficulty finding words, understanding speech, or safely
swallowing (coughing on liquids) should be referred to SLP. For example, clinicians should refer
patients with suspected cognitive-communication deficits (attention, memory, executive
impairment) for SLP evaluation. SLP input is also critical in late-stage dysphagia management in
dementia.

Voice and Laryngeal Disorders:

Adults with persistent hoarseness (>2–4 weeks) should first have medical evaluation (ENT), but
chronic functional dysphonia, spasmodic dysphonia, or post-laryngectomy voice restoration
require SLP intervention. Similarly, patients with hypernasal speech post head/neck cancer
surgery may need SLP therapy or palatal lift.

Individuals with cleft palate repairs, cerebral palsy, or cognitive impairments (e.g. intellectual
disability) affecting communication should be seen by SLP. Children or adults with a “mixed”
diagnosis (e.g. Down syndrome, fragile X) typically warrant speech therapy for the associated
language and oral-motor deficits.

2. DISCUSS DEGREE OF EAR DEAFNESS THAT WOULD REQUIRE

HEARING AIDS
Hearing is essential for communication, learning, and social interaction. Hearing loss,
also known as deafness, occurs when there is a reduction in the ability to perceive
sound, and it can range from mild impairment to complete loss of hearing. The severity
of hearing loss is usually classified based on the hearing threshold measured in decibels
(dB), which helps guide both diagnosis and management.

The use of hearing aids is one of the most effective interventions for patients with
significant hearing impairment, particularly when the loss affects daily communication.
However, not all degrees of hearing loss require amplification, and the decision to
prescribe hearing aids depends on the severity of deafness, the type of hearing loss, and
the functional impact on the patient.

Degrees of Hearing Loss and Functional Effects

Hearing loss is classified by the pure-tone average (PTA) of thresholds at 500, 1000,
2000, and 4000 Hz (in dB HL). ASHA (Clark, 1981) defines mild hearing loss as 26–40 dB
HL, moderate 41–55 dB, moderately severe 56–70 dB, severe 71–90 dB,
and profound >90 dB. (WHO similarly uses mild, moderate, severe, profound categories.)
 Functionally, a mild loss means soft or distant speech is missed. An individual with mild
loss often hears vowels clearly but misses soft consonants, leading to frequent requests
for repetition. Moderate loss makes normal conversation difficult – the person hears
some speech but cannot understand it reliably without a device. With a moderately
severe to severe loss, conversational speech is almost entirely inaudible; even shouting
is hard to understand. Profound loss implies minimal or no auditory perception of
speech; the person may only sense very loud sounds (fire alarm, plane).

 Normal hearing (–10 to 15 dB HL)

  PTA: –10 to 15 dB HL

 Functional: no hearing deficit (hears all speech clearly)

 Causes: none (normal hearing)

 Interventions: none (routine monitoring)

 Slight loss (16 to 25 dB HL)

 PTA: 16 to 25 dB HL

 Functional: may miss very soft speech; essentially normal in daily conversation

 Causes: minor conductive issues (e.g. cerumen, mild otitis media)

 Interventions: none or observation (no assistive device needed)

 Mild loss (26 to 40 dB HL)

 PTA: 26 to 40 dB HL
 Functional: difficulty hearing faint speech and consonants
 Causes: chronic otitis media, early SNHL (noise/genetic), early otosclerosis
 Interventions: consider hearing aid if communication is affected

(e.g. in noise or group settings)

 Moderate loss (41 to 55 dB HL)

 PTA: 41 to 55 dB HL
 Functional: conversational speech is hard to follow; hearing is significantly impaired
 Causes: long-standing SNHL (presbycusis, noise), otitis media sequela, Meniere’s disease
 Interventions: hearing aids indicated (binaural fitting if bilateral)

 Moderately severe loss (56 to 70 dB HL)

 PTA: 56 to 70 dB HL

 Functional: most speech is inaudible without amplification

 Causes: severe SNHL (meningitis, ototoxicity), advanced presbycusis

 Interventions: hearing aids (verify benefit); evaluate for cochlear implant if

needed
  Severe loss (71 to 90 dB HL)

 PTA: 71 to 90 dB HL

 Functional: only very loud speech or sounds are heard; communication is

extremely limited

 Causes: profound SNHL (genetic, infection, acoustic neuroma)

 Interventions: powerful hearing aids; recommend cochlear implant evaluation

Profound loss (>90 dB HL)

 PTA: >90 dB HL
 Functional: little or no hearing; speech is essentially inaudible
 Causes: congenital deafness, severe SNHL (post-meningitis, ototoxicity)
 Interventions: cochlear implant is indicated

; use of sign language/AAC as needed

Hearing-Aid Indications (Adults vs. Children)

 Adults:
Hearing aids are indicated for adults whose hearing loss affects
communication (including hearing warning signals and background awareness). National
guidelines (e.g. NICE NG98) state that aidable hearing loss – even mild to moderate –
should be managed with amplification if the person perceives functional difficulty. In
bilateral hearing loss, fitting two hearing aids is recommended to improve speech clarity
in noise and sound localization. There is no absolute dB cutoff; rather, candidacy
depends on speech recognition. (Some audiology guidelines note that aided speech
recognition <70–80% or PTA >40–50 dB often prompts referral for amplification.) Severe
(>70 dB) losses are usually amplified with powerful hearing aids, but if aided
understanding remains poor, cochlear implant (CI) evaluation is considered.

 Children:
Pediatric amplification criteria are more aggressive. Any permanent bilateral hearing
loss ≥25 dB HL in children is typically fitted with hearing aids as early as possible (often
by 6 months) to support language acquisition. For unilateral losses, management
depends on degree; even unilateral moderate SNHL can affect classroom learning.
Candidacy often includes any confirmed loss where speech/language delay is likely. The
1-3-6 guideline (screen by 1 month, diagnose by 3 month, intervene by 6 month) is the
standard for newborn hearing programs. In summary, whereas some adults with mild
loss may forego aids, children with even mild bilateral loss usually receive amplification
early.