A child should be assessed by a speech-language pathologist if they are not babbling by 12 months, have no words by 18 months, have fewer than 50 words or no two-word combinations by 24 months, cannot be understood by their parents at 3, show signs of stuttering that persist, or lose skills they once had. In Ontario, families can self-refer for a free assessment without a doctor’s note. This guide goes through the signs by age, what an assessment involves, and why “wait and see” is usually not a good plan.
Referral triggers by age
The table below pulls together the signs that speech-language pathologists and public programs most often use as reasons to assess. They are drawn from the ASHA 2023 communication milestones, which Speech-Language & Audiology Canada endorsed in 2024, and from the screening benchmarks used by Ontario’s Preschool Speech and Language Program.
| Age | Reasons to book an assessment |
|---|---|
| By 6 months | Does not startle at loud sounds, does not turn toward voices, does not coo or laugh |
| By 12 months | No babbling with consonants (“baba”, “mama”), does not respond to their name, does not use gestures such as pointing, waving or reaching to be picked up |
| By 18 months | No words, does not follow simple directions, does not point to show you things, does not seem to understand familiar words |
| By 24 months | Fewer than 50 words, no two-word combinations, mostly uses gestures or sounds instead of words, cannot point to pictures when named |
| By 3 years | Parents cannot understand most of what the child says, no short sentences, does not ask questions, does not follow two-step directions, frustration when trying to communicate |
| By 4 years | Unfamiliar adults understand less than most of what the child says, leaves out sounds or syllables, cannot tell a simple story or answer “who”, “what” and “where” questions |
| Any age | Loss of words or skills, any concern about hearing, stuttering with tension or struggle, stuttering that lasts more than 6 to 12 months or starts after age 3 and a half, a family history of speech or language difficulty, very limited interest in interacting with people |
If you want to go through the full milestone list, the free milestone checklist covers understanding, talking and social communication by age. Our guide to speech and language milestones by age explains the numbers behind each row.
A few of these deserve more detail.
Late talkers at 2
A 2-year-old with fewer than 50 words and no word combinations is usually described as a late talker. The ASHA Practice Portal on late language emergence notes that many late talkers do catch up by school age, but a meaningful share go on to have persistent language difficulties, and it is not possible to tell from a single visit which group a child belongs to. Risk is higher when understanding is also delayed, when the child uses few gestures, or when there is a family history. Our guide for parents of late talkers covers this in depth.
Speech that is hard to understand
Clinicians often use a rule of thumb for how much an unfamiliar adult should understand: about half at age 2, three-quarters at age 3, and nearly all by age 4. Parents usually understand more than strangers, so if you as a parent struggle to understand your 3-year-old, that is a clear reason to refer. The intelligibility estimator can help you put a rough number on it.
Stuttering
Many children repeat words or sounds between ages 2 and 4 while their language is growing fast, and most of this resolves on its own. An assessment is recommended when stuttering has lasted more than 6 to 12 months, involves physical tension or struggle, began after age 3 and a half, runs in the family, or upsets the child. Our guide on stuttering in toddlers and preschoolers describes the difference between typical disfluency and stuttering.
The “wait and see” myth
Parents are often told that a child will “grow out of it”, that “boys talk later”, or that “Einstein didn’t talk until he was 4”. Each of these has a grain of truth and misses the bigger picture.
It is true that some children who are late to talk catch up. It is also true that a large group does not, and that no one can reliably tell which child is which at 18 or 24 months. Waiting to find out means a child who needs support spends months or years without it, during the period when language is growing fastest.
Research also supports acting early. A meta-analysis by Roberts and Kaiser (2011) of parent-implemented language interventions found that teaching parents specific strategies led to meaningful gains in children’s receptive and expressive language. Those strategies are simple, take place in daily routines, and are most effective when they begin young. Early support is not about pressure. It is about making the help easier and giving families clarity.
There is also a practical reason not to wait in Ontario. The Preschool Speech and Language Program serves children until they start school, and some regions have waiting lists. Referring at 18 months rather than 3 years means the assessment and any support happen with time to spare before junior kindergarten.
None of this means every late-ish milestone needs a clinic visit. It means that when a referral trigger on the list above is present, an assessment is a sensible, low-cost step rather than something to put off.
Check hearing first
Hearing is the first thing to rule out whenever there is a speech or language concern. Ontario’s Infant Hearing Program screens newborns, but hearing can change afterward. Repeated ear infections and fluid behind the eardrum (otitis media with effusion) are common in toddlers and can cause mild, fluctuating hearing loss that is easy to miss. A child who hears speech as muffled for months at a time may learn sounds and words more slowly.
Signs worth noticing include turning up the television, not responding when called from another room, saying “what?” often, and speaking loudly or unclearly. Your child’s doctor can look at the ears and refer to an audiologist. In Ontario, audiologists are regulated by the same college as speech-language pathologists, and many Preschool Speech and Language agencies will ask for a recent hearing test as part of the referral.
What a speech and language assessment involves
An assessment with a registered speech-language pathologist usually takes one to two hours, sometimes across two visits. For young children, it looks a lot like play. Here is what typically happens.
Parent interview. The clinician asks about pregnancy and birth, hearing, ear infections, developmental history, languages spoken at home, family history, and what you have noticed. Your observations carry real weight because you see your child across many settings.
Observation and play. The speech-language pathologist plays with your child and watches how they communicate: eye contact, gestures, turn-taking, how they ask for things, what sounds and words they use, and how they respond to what is said to them.
Standardized tests or checklists. Depending on age, the clinician may use a parent-report vocabulary checklist, a picture-naming test, or a test of understanding. Older preschoolers may be asked to repeat words, name pictures and follow directions. For children who speak more than one language, the clinician should ask about both languages and may use an interpreter.
Speech sound and oral-motor check. The clinician listens to which sounds your child uses and leaves out, and may look at how the lips, tongue and jaw move during eating and talking.
Feedback and plan. You should leave with a clear description of your child’s strengths and areas of need, whether follow-up is recommended, and what to do at home. Options include monitoring with a recheck in a few months, parent coaching, group programs, or individual therapy. Our guide on questions to ask before starting speech therapy can help you prepare.
How to get an assessment in Ontario
Ontario families do not need a doctor’s referral or a diagnosis to access publicly funded speech and language services for preschoolers.
Preschool Speech and Language Program (PSL). Free for children from birth until they start junior kindergarten. Families self-refer by calling their local lead agency (for example Surrey Place in Toronto or ErinoakKids in Peel). In many regions, a SmartStart Hub is the single point of access for all child development concerns. The Ontario services finder lists the contact for your area.
School-age children. Once a child starts school, speech and language support comes through the school board and through School-Based Rehabilitation Services at Children’s Treatment Centres. Speak to the classroom teacher or principal to start a referral.
Private speech-language pathologists. Families can also book directly with a private clinician. OHIP does not cover private services, but many extended health plans cover part of the cost. Before booking, confirm the person is on the CASLPO Public Register using our guide on checking whether a speech-language pathologist is registered. The speech therapy cost calculator gives typical price ranges.
Our full guide on how to get speech therapy in Ontario walks through each route step by step.
What you can do while you wait
A referral does not mean you have to pause. The strategies speech-language pathologists teach parents work in everyday routines: get face to face, follow your child’s lead in play, wait for them to take a turn, repeat what they say and add a word, and read together daily. Our guide on everyday strategies to help your child talk explains each one.
Keep a short list of the words your child says and the things you notice. It will be useful at the assessment, and it often shows progress that is easy to miss day to day. Trust your instincts. Parents are usually the first to notice when something is different, and asking for an assessment is the simplest way to find out.
Sources
- ASHA: Communication milestones (2023)
- ASHA Practice Portal: Late language emergence
- Speech-Language & Audiology Canada
- Ontario Preschool Speech and Language Program
- Ontario Infant Hearing Program
- Roberts & Kaiser (2011): The effectiveness of parent-implemented language interventions, a meta-analysis
- SickKids AboutKidsHealth
How this guide was written
Written by the Speechie team. Every clinical claim is tied to a published source listed above. Guides are reviewed when the underlying guidance changes and the date shown above reflects the last substantive update. This is general information, not individual advice, and not a substitute for assessment by a registered speech-language pathologist. In Ontario, families can self-refer to their local Preschool Speech and Language Program at no cost.