PEDIATRICS: Fluency Guidelines for Referral to Speech-Language Pathologists (SLPs)

REFERRAL:Pediatric Fluency Referral Guidelines, Page 1 of 2
Most Common Etiologies:
• Cerebral palsy
• Developmental stuttering or cluttering
• Language impairment
• Traumatic brain injury (TBI)

Related Terms:
Apraxia of speech, avoidance behavior, block, circumlocution, cluttering, developmental disfluency, dysarthria, eye contact, perseveration, prolongation, prosody, repetition, revision, slurred speech, sound distortion, sound omission, sound substitution, stammer

Potential Consequences:
• Difficulty expressing basic needs and providing routine information
• Embarrassment, anger, anxiety, fear, and/or frustration from awareness of speech disfluencies
• Avoidance of situations, words, and sounds that are likely to cause disfluencies
• Avoidance of communication with certain individuals (such as a teacher or principal)
• Social and/or emotional isolation (which can result from or worsen withdrawal, reduced self-esteem, and/or depression)

Behaviors1 That Should Trigger an SLP Referral
Preschool-age child
• frequently reacts to repetitions and/or prolongations; for example, child becomes intolerant of occasions when he repeats a syllable a few times, calls attention to disfluency, and disrupts conversation (e.g., “I bro-bro-bro–Mommy, I can’t say that …”)
• parent/caregiver reacts to child’s repetitions and/or prolongations; child notices adult behavior and becomes concerned also
• observable signs of muscle tension during disfluencies
• exhibits observable escape behaviors (e.g., eye blinks, head nods, and “ums”)
• demonstrates awareness of disfluencies and feelings of frustration
• caregivers and/or parents exhibit concern that the child’s disfluencies are a problem

School-age child
• child, parents, and/or teachers exhibit concern about disfluencies
• obvious sound repetitions, prolongations
• muscle tension may cause child to shut off sound or voice momentarily during speech
• use of escape behaviors, such as looking away from speaker, to end episode
• avoidance behaviors emerge from feared words, situations and/or people where child anticipates being disfluent

• more severe disfluencies than described for school-age children (e.g., muscle tension with disruption of speech is often more severe and includes lip, tongue, and jaw tremors
• complex, habitualized patterns of avoidance (e.g., avoiding certain words that are more likely to produce disfluency) and escape behaviors (e.g., taps fingers on desk while speaking in attempt to avoid or end a disfluency) from repeated suppression of disfluencies
• increased fear and embarrassment that negatively affect self-concept (such as feeling that teacher thinks less of them, perhaps that they are less intelligent, due to disfluencies)
1Behaviors are clustered to indicate different levels of function and/or patterns commonly associated with different medical conditions or etiologies.