Educational draft · awaiting clinical reviewThe full textbook explains uncertainty but does not replace live national or local guidance, specialist advice, or current prescribing information.
Speech, language and hearing assessment
Paediatrics and child health · UK scope · Sources checked 27 Aug 2026 · Clinical review pending
!
Acute loss or disruption of communication
Sudden slurred, absent or disordered speech can reflect stroke, seizure, encephalitis, intoxication, metabolic disturbance or airway and bulbar disease rather than developmental delay.
Action: Use ABCDE, check glucose and obtain an exact onset and last-known-well time. New dysarthria, aphasia, facial asymmetry, weakness, ataxia, altered consciousness or severe headache needs immediate paediatric neurological and emergency imaging assessment; follow the local paediatric stroke or seizure pathway where relevant. Drooling with inability to swallow, stridor, choking or aspiration requires urgent airway and feeding-safety management. Treat suspected meningitis, encephalitis, poisoning or hypoglycaemia promptly. Do not send an acutely changed child to a routine speech-and-language waiting list.
Purpose and principles
Distinguish speech, language, communication, fluency, voice and hearing concerns, identify urgent neurological or safeguarding presentations, select age-appropriate audiology and speech-language assessment, and coordinate early support without waiting for diagnostic certainty.
Communication is a developmental system rather than one milestone. Speech describes articulation, phonology, motor planning and intelligibility. Language includes comprehension, vocabulary, grammar and narrative. Pragmatics covers reciprocity, inference and adapting communication to context. Fluency includes stammering, and voice concerns include persistent hoarseness, abnormal pitch or resonance. Naming the affected domain directs assessment and prevents a child with good pronunciation but poor understanding being falsely reassured.
Begin with caregiver and child concerns and concrete examples. Establish languages heard and used, hearing-screen history, ear disease, family history, pregnancy and neonatal factors, feeding and oral-motor development, developmental milestones, regression, education and social communication. Ask which communication mode works best, how unfamiliar listeners understand the child, and whether behaviour occurs when needs cannot be expressed. Obtain nursery or school observations because demand and acoustic environment vary.
Practice
Two practice questions
Your practice draft is saved in this browser.
Question 1 of 2
0 correct
Paediatrics and child healthOriginal SBA
Language delay after newborn screening
A 2-year-old passed the newborn hearing screen but now uses no meaningful words and responds inconsistently when called, especially in background noise. What is the best next step?
Sources and review status4 sources · checked 27 Aug 2026 · clinical review pending+
Sources
Sources and review status
National guidance is shown before implementation-dependent detail. Apply principles in context and verify current guidance when a decision affects care. Source check completed 27 Aug 2026; clinical approval remains outstanding.
Observe spontaneous play and interaction before formal testing. Note shared attention, gesture, turn taking, imitation, symbolic play, comprehension of increasingly complex instructions, vocabulary, sentence structure, intelligibility, fluency, voice and repair when misunderstood. Use the child's usual communication, including sign, symbols or a device. A silent or distressed clinic encounter is not a valid language sample.
Examine growth, head circumference and neurological status when development is concerning. Inspect pinnae and canals and perform otoscopy for wax, infection, perforation, retraction or effusion. Examine palate, dentition, tongue movement and facial symmetry; observe breathing, drooling and swallow safety. Enlarged tonsils, mouth breathing and snoring suggest sleep-disordered breathing. Dysmorphism, weakness, ataxia or abnormal reflexes changes the referral pathway.
Speech-sound disorder may be articulation based, phonological or motor-planning related. Consistent developmental sound-pattern errors differ from variable errors, disrupted prosody and oral-motor planning difficulty. Structural cleft or velopharyngeal dysfunction may cause hypernasality and nasal air escape. Persistent hoarseness needs voice hygiene review and ENT visualisation when prolonged or accompanied by airway features; children should not be taught to force a different voice without assessment.
Language disorder can be expressive, receptive or mixed and may occur alone or with intellectual disability, autism, hearing loss, brain injury or a genomic condition. Receptive difficulty is particularly easy to mistake for inattention or non-compliance. Developmental language disorder describes persistent functional language difficulty not better explained by a known biomedical condition, but support should be based on need rather than delayed for terminology.
Stammering often varies with excitement, fatigue and linguistic demand. Repetitions of whole words can occur during normal development, while tension, blocks, sound prolongation, avoidance and distress support specialist referral. Do not tell a child to slow down or repeatedly restart. Give time, maintain natural eye contact and reduce conversational pressure. Sudden acquired dysfluency with neurological change requires urgent assessment.
Hearing loss may be conductive, sensorineural, mixed or neural. Otitis media with effusion causes fluctuating conductive loss and is common in early childhood. Sensorineural loss may be congenital, progressive or acquired from infection, ototoxic exposure or other causes. Auditory neuropathy affects neural synchrony. Unilateral or mild loss still impairs localisation, speech in noise and classroom access and should not be dismissed because conversational speech seems adequate.
The UK newborn hearing programme identifies many congenital bilateral losses early using otoacoustic emission and, where indicated, automated auditory brainstem response. It is a screen at one point in time. Parental concern, delayed speech, regression or inconsistent response later always justifies new hearing assessment, regardless of a documented pass.
Bilingual children distribute knowledge across languages and may mix language normally. A disorder affects learning and use across the child's languages, although severity may differ with exposure. Use trained interpreters rather than siblings, document exposure history and avoid English-only norms that classify difference as disorder. Hearing aids, sign language and augmentative communication should be accessible in all important environments.
Management is multidisciplinary. Audiology defines hearing access; ENT treats selected middle-ear or structural disease; speech and language therapy profiles communication and swallowing; education provides acoustic and language adaptations; paediatrics evaluates global development, regression or syndromic features. Agree one plan with the family so serial referrals do not postpone usable support.
Key points
Define the concern: speech is sound production, language is understanding and formulation, pragmatic communication is social use, fluency is flow, and voice is quality or resonance.
Assess receptive language separately from expressive language; a child who speaks little may understand well, while fluent speech can conceal poor comprehension.
A passed newborn hearing screen does not exclude unilateral, mild, acquired, fluctuating, progressive or auditory-neuropathy-spectrum hearing loss.
First-line assessment combines developmental and communication history, multi-setting observation, ear and oral examination, formal audiology and speech-and-language therapist assessment when indicated.
Choose hearing tests by developmental ability, not age alone: visual reinforcement audiometry for many infants, play audiometry for preschool children and pure-tone audiometry for cooperative older children.
Tympanometry assesses middle-ear mechanics and supports diagnosis of effusion but is not a hearing-threshold test.
For suspected otitis media with effusion, NICE formal assessment includes otoscopy, hearing testing and tympanometry.
Indications, selection and cautions
Speech-sound presentation
Comprehension and ideas may be age appropriate but pronunciation, phonological pattern, motor planning or intelligibility limits successful communication.
Expressive-language presentation
Vocabulary, grammar, sentence formulation or narrative lags behind comprehension, with frustration when the child cannot communicate complex ideas.
Receptive-language presentation
The child misunderstands questions or instructions, relies heavily on context and may appear inattentive, oppositional or socially withdrawn.
Pragmatic-communication presentation
Reciprocal conversation, inference, shared attention and adaptation to context are difficult, prompting autism and broader developmental assessment.
Hearing-access presentation
Inconsistent response, increased volume, watching faces, speech-in-noise difficulty or unclear speech may reflect fluctuating, unilateral or bilateral loss.
Fluency, voice or resonance presentation
Blocks, prolongations, tension, persistent hoarseness, hypernasality or nasal escape requires domain-specific SLT and sometimes ENT assessment.
Red flags requiring action
Loss of previously established words, comprehension, social communication or motor skill is developmental regression and requires prompt paediatric or neurological assessment.
Method and interpretation
01First-line: integrated developmental and communication historyFirst stepFirst line
Why
Define domain, onset, trajectory, regression, languages, functional impact, hearing and medical context across settings.
Interpretation and limitations
History directs tests but does not substitute for observing the child's best communication mode and obtaining nursery or school collateral.
02Reference standard: comprehensive audiological assessmentReference standard
Why
Estimate ear-specific hearing thresholds and type of loss using developmentally appropriate behavioural and objective measures.
Interpretation and limitations
No single test is universal; audiology integrates behavioural responses, air and bone conduction, tympanometry, emissions and electrophysiology as needed.
03Speech and language therapist assessment
Why
Profile speech sounds, receptive and expressive language, pragmatics, fluency, voice, oral motor skill and communication participation.
Interpretation and limitations
Use appropriate norms, language samples and interpreter support; standard scores are invalid when linguistic or developmental assumptions are unmet.
04Otoacoustic emissions
Why
Clinical next steps
01Initial assessmentDefine domain and urgencyFirst stepA child is not communicating as expected or hearing is questioned.+
1Determine whether change is acute or regressive and assess swallowing, neurological, infectious, ENT and safeguarding red flags.
2Take a multi-language developmental and medical history, observe spontaneous communication and examine ears, mouth, growth and neurology as indicated.
3Arrange formal audiology and SLT or wider developmental referral according to the pattern while starting practical communication support.
02AudiologyMatch the method to developmentHearing loss is possible despite screening history.+
1Use ear-specific behavioural audiometry suitable for developmental ability and combine it with otoscopy and tympanometry.
2Add otoacoustic emissions or diagnostic auditory brainstem responses when the question or reliability requires objective physiology.
Risks, monitoring and follow-up
Record the child's functional communication at home and in education, not only clinic test scores, and review whether agreed adaptations are consistently available.
Repeat hearing assessment after middle-ear disease, inconsistent behavioural results or a progressive-risk history; a previous normal test does not override new concern.
For bilateral OME with hearing loss, repeat formal hearing assessment after 3 months unless impact warrants earlier intervention; provide access strategies during observation.
Track receptive and expressive language, intelligibility, social communication, fluency, participation and distress against individual goals rather than comparison alone.
Monitor hearing-aid or device use, ear health, earmould fit, battery and school technology, and explore barriers without blaming the child or family.
Recheck growth, feeding safety, aspiration symptoms and nutritional adequacy when oral-motor or swallowing difficulty accompanies communication concerns.
Escalate any loss of skills, emerging seizures, focal neurological signs, persistent hoarseness with airway symptoms or deterioration despite intervention.
At education transitions, transfer the communication profile, preferred supports and hearing-access plan with consent so the child does not repeatedly prove the same need.
Special situations
A screen is time limited
Passing newborn screening does not protect against later conductive, progressive, unilateral or acquired hearing loss.
Tympanometry is not audiometry
It describes middle-ear mechanics; a child still needs hearing assessment to determine threshold and functional impact.
Comprehension can hide
Social copying and contextual cues may conceal receptive-language difficulty until instructions become abstract or multi-step.
All languages count
A bilingual child should be assessed across the languages they use; language difference is not evidence of disorder.
AAC supports development
Sign, symbols and communication devices provide immediate agency and can complement rather than prevent spoken language.
Behaviour may be communication
Distress during demands can reflect misunderstood language, pain, sensory overload or inability to express a need.
Common pitfalls
01
Do not reassure solely because the newborn hearing screen was passed.
02
Do not use one milestone as a diagnosis or delay referral until several are missed.
03
Do not confuse clear articulation with normal language comprehension or social communication.
04
Do not interpret bilingual exposure or accent as the cause of a language disorder.
05
Do not use tympanometry alone to quantify hearing or rule out sensorineural loss.
06
Do not diagnose non-compliance before assessing receptive language and hearing.
07
Do not order routine MRI, EEG or genomic tests for isolated speech delay without clinical indications.
08
Do not use antibiotics, oral or nasal corticosteroids, antihistamines or decongestants to treat uncomplicated OME.
09
Do not
Reassess bilateral OME with hearing loss after 3 months; intervene earlier when hearing difficulty significantly affects daily living, communication or development.
Bilingual or multilingual exposure does not cause language disorder. Assess every language with trained interpreters and culturally appropriate methods.
Refer early and provide communication support while assessment proceeds; augmentative and alternative communication supports language and does not prevent speech development.
Treat the functional access problem: improve hearing, interaction, education, environment and communication rather than chasing a single test score.
Sudden speech change, dysarthria, facial weakness, ataxia, seizures or altered awareness requires emergency assessment rather than developmental surveillance.
No response to sound, marked asymmetry, progressive hearing difficulty, persistent unilateral tinnitus or vestibular symptoms needs formal audiology and cause-specific review.
Persistent or recurrent otorrhoea, mastoid tenderness, post-auricular swelling, systemic illness or facial weakness requires urgent ENT or paediatric assessment.
Coughing, choking, wet voice, recurrent chest infection, prolonged meals or weight faltering suggests unsafe swallowing and needs prompt feeding and aspiration assessment.
No babble or communicative gesture around 12 months, no meaningful words by about 18 months or no spontaneous two-word phrases by about 24 months is a prompt for assessment, not a threshold for passive waiting.
Poor shared attention, reduced response to name, repetitive behaviour or rigid sensory patterns requires wider developmental and autism-focused assessment as well as hearing evaluation.
Injury patterns, sexualised language, fear, neglect, family concern or communication barriers increasing vulnerability must trigger safeguarding enquiry and accessible disclosure support.
Detect sound generated by functioning cochlear outer hair cells as a rapid objective screen.
Interpretation and limitations
Absent emissions may reflect cochlear dysfunction or middle-ear blockage; present emissions do not prove normal thresholds or exclude neural hearing disorder.
05Auditory brainstem response
Why
Measure electrophysiological response along the auditory nerve and brainstem, including when behavioural testing is unreliable.
Interpretation and limitations
Automated ABR screens newborns; diagnostic frequency-specific ABR estimates thresholds but must be integrated with middle-ear and cochlear findings.
06Tympanometry and otoscopy
Why
Assess middle-ear pressure and mobility and identify effusion, perforation, wax, infection or structural abnormality.
Interpretation and limitations
A flat trace can support effusion but tympanometry does not quantify functional hearing; formal OME assessment includes hearing testing as well.
07Age-appropriate behavioural audiometry
Why
Use visual reinforcement, conditioned play or pure-tone response to estimate functional ear-specific thresholds.
Interpretation and limitations
Select by developmental ability and test reliability; inconsistent response may require repeat or objective assessment, not assumptions about behaviour.
08Targeted developmental, genomic or neurological assessment
Why
Investigate global delay, regression, seizures, dysmorphism, weakness or another aetiological clue.
Interpretation and limitations
Routine MRI, EEG or laboratory panels are not speech-delay tests; choose investigations from the wider phenotype and current pathways.
3Classify degree, type, symmetry and functional impact, then refer appropriately for amplification, ENT care or aetiological assessment.
03OMEAssess and review stepwiseOtitis media with effusion may be affecting hearing.+
1Confirm with formal assessment including otoscopy, hearing testing and tympanometry; document impact on communication, education and daily life.
2For bilateral OME with hearing loss, reassess hearing after 3 months; consider a similar review for unilateral loss but intervene earlier when daily impact is substantial.
3Discuss hearing devices, autoinflation when the child can engage, grommets and selected adenoidectomy through shared decision making; do not use ineffective routine drug treatments.
04Communication supportIntervene before labels are finalCommunication difficulty affects participation or behaviour.+
1Optimise hearing and visual access, reduce background noise, gain attention before speaking and use short language with processing time.
2SLT and education agree goals for the affected domain and coach caregivers and staff in responsive interaction within everyday routines.
3Provide sign, symbols or an augmentative communication system when useful and assess autism, cognition, motor function or genomic cause when the wider pattern indicates.
05EscalationRoute regression and focal findingsEscalationSkills are lost or examination is abnormal.+
1Treat acute focal speech loss, altered consciousness, seizure or bulbar dysfunction as an emergency.
2Refer motor regression at any age or language regression after age 3 first to paediatrics or neurology; assess hearing in parallel.
3Refer language or social regression under age 3 to the autism team while ensuring paediatric review for neurological or systemic features.
postpone sign, symbols, acoustic adjustment or SLT input while waiting for a final label.
10
Do not route acute speech loss, regression or unsafe swallowing to routine developmental follow-up.