Step 1 of 8
Presentation & Red-Flag Screening
Paediatric (delayed speech/language, feeding) vs adult (aphasia, dysarthria); screen for regression and acute/progressive neuro red flags
Communication concerns present very differently across the lifespan. Paediatric presentations include delayed speech or language, poor intelligibility, limited vocabulary, difficulty understanding language, reading difficulty and academic underachievement, social-communication deficits, and feeding or oral-motor difficulties. Adult presentations include aphasia, dysarthria, apraxia of speech, voice change, cognitive-communication deficits, communication decline after stroke or traumatic brain injury, and progressive language deterioration.
Before any detailed assessment, the patient is screened for red flags that demand urgent referral. The paediatric red flags are no babbling by 9 months, no words by 16 months, no two-word phrases by 24 months, loss of previously acquired speech or language, feeding/swallowing difficulty, suspected hearing loss, neurological deficit, and craniofacial anomaly. The adult red flags are sudden aphasia, acute dysarthria, new neurological deficit, suspected stroke or TIA, rapid cognitive decline, progressive bulbar symptoms, and severe dysphagia. Where any is present, the patient is referred immediately to neurology, ENT, or emergency services — a sudden aphasia is a stroke pathway, not a speech-therapy waiting list. Where none is present, the comprehensive evaluation proceeds.
- Paediatric — delayed speech/language, poor intelligibility, comprehension/reading difficulty, social-communication, feeding/oral-motor
- Adult — aphasia, dysarthria, apraxia, voice change, cognitive-communication, post-stroke/TBI decline, progressive deterioration
- Paediatric red flags — no babble by 9 mo, no words by 16 mo, no 2-word phrases by 24 mo, regression, feeding difficulty, suspected hearing loss, neuro deficit
- Adult red flags — sudden aphasia/dysarthria, new deficit, stroke/TIA, rapid cognitive decline, progressive bulbar, severe dysphagia → emergency referral
★ High-yield pearls (chapter-wide)
- Audiological evaluation is a mandatory early step in every communication disorder — undetected hearing loss masquerades as a speech or language disorder, and it must be treated before the speech-language assessment is interpreted.
- Loss of previously acquired speech or language is a red flag at any age — in a child it demands urgent developmental and neurological evaluation, and in an adult it points to stroke, tumour, or a neurodegenerative process.
- Sudden aphasia or dysarthria is a stroke until proven otherwise — it is an emergency referral, not a speech-therapy referral.
- Classify the disorder by domain first — speech, language, social-communication, cognitive-communication, or feeding/swallowing — because the assessment battery and the therapy differ completely between them.
- Developmental milestones are the paediatric screen — no babbling by 9 months, no words by 16 months, and no two-word phrases by 24 months each warrant evaluation.
- A language delay with echolalia, poor joint attention, limited eye contact, and restricted interests should trigger autism screening (M-CHAT-R, ADOS-2) and a developmental-paediatric referral.
- Speech-sound disorders are not all the same — articulation, phonological, and childhood apraxia of speech need different therapies, and motor-speech disorders (apraxia, dysarthria) are distinguished on the oral-mechanism examination.
- Severe, persistent communication limitation is an indication for augmentative and alternative communication (AAC) — no-tech, low-tech, or high-tech — introduced alongside, not instead of, speech and language therapy.
- Therapy intensity is matched to severity, and progress is re-measured — an initial trial of roughly 12–24 sessions over three months, then reassess the diagnosis, adherence, and intensity if progress stalls.
- Communication disorders are managed by a team — audiology, ENT, neurology, developmental paediatrics, neuropsychology, education, and speech-language pathology — coordinated through an IFSP (birth–3), an IEP (3–21), or an adult rehabilitation plan.
Evidence base
3 sources- HIGH
Visch-Brink E & Breitenstein C · Eur Stroke J · 2025Practice guidelinePMID 40401776
European Stroke Organisation guideline on the assessment and rehabilitation of post-stroke aphasia, framing intensity, timing, and approaches to aphasia therapy.
- HIGH
Togher L, Douglas J, Turkstra LS · J Head Trauma Rehabil · 2023Practice guidelinePMID 36594860
INCOG 2.0 guideline on the rehabilitation of cognitive-communication and social-cognition disorders after traumatic brain injury, the evidence-based framework for cognitive-communication therapy.
- MOD
Wilkinson JM, Codipilly DC, Wilfahrt RP · Am Fam Physician · 2021ReviewPMID 33448766
Review of the evaluation and collaborative management of dysphagia, covering the clinical swallow assessment, instrumental studies, and the role of aspiration risk.
Decision tree
The triage screen is the first gate. Classification routes the stable patient to one of the aetiology-keyed pathways below. Cross-cut cards capture the chapter's must-not-miss rules.