Chapter 5 ‘Common’, ‘best’ and evidence-based practice In Chapter 5, contributors working in Australia, Canada, Germany, New Zealand, the United Kingdom and the United States present information, opinions and reflections on clinical ‘common’, ‘best’ and evidence-based practice (EBP). The questions that are put to them vary considerably, covering diverse issues and canvassing a range of views. In A30, Nicole Watts Pappas appraises several studies of SLP/SLT clinical ‘common practice’ in child speech, with an emphasis on family-centred practice in Australia. Megan Hodge (A31) follows with insights into clinical practice gained from a survey of Canadian SLPs’ opinions and experience using non-speech oral motor exercises (NS-OME) in children’s speech therapy. Next, Gail Gillon (A32) discusses effective practice and positive and enduring partnerships between SLT and Education in New Zealand. Kylie Toynton (A33), a speech pathologist in private practice in an Australian rural setting broaches the issues that arise when SLPs/SLTs use (largely nonevidence-based) software applications (Apps) in working with children with speech sound disorders (SSD). Drawing on the results of a survey of clinicians, Victoria Joffe (A34) examines minimalist assessment practices in the United Kingdom. Echoing Hodge (A31), Gregory Lof (A35) then talks about the puzzling situation wherein large numbers of north American SLPs, who have been steeped, at Master’s level, in scientific method and critical analysis of the evidence base, continue to implement a therapy methodology with children with SSD that is anything but scientific (McCauley, Strand, Lof, Schooling & Frymark, 2009). These six contributions are followed by discussion of four related issues. Karen McComas (A36) reflects on the transformation from student to ethical practitioner that occurs when a student participates in integrated, educative experiences (Palmer & Zajonc, 2010); B. May Bernhardt and Angela Ullrich (A37) review the role of linguistic theory, particularly non-linear phonology, in clinical problem solving; Karen Froud (A38) has interesting things to add about reading and critically evaluating the literature around the so-called ‘terrifying therapies’ (Gardner, A27; Joffe, A34) and the research-practice gap; and Thomas Powell (A39) presents a multifaceted model for ethical practices.
Some years ago I had the pleasure of joining Nicole Watts Pappas and seventy other contributors to Sharynne McLeod’s remarkable 2007 book, The International Guide to Speech Acquisition . In our chapter on speech acquisition and the family (Watts Pappas & Bowen, 2007, p 89) we wrote the following.
Dr. Nicole Watts Pappas is actively engaged in research, publication and SLP clinical practice in a community clinic in Brisbane, Australia, where she endeavours to use family-centred approaches in her work with young children and their families. In her PhD research, she explored the involvement of families in SLP/SLT intervention for speech impairment.
Q30. Nicole Watts Pappas: Family-centred speech intervention in Australia The distinction between involving parents in their own children’s speech intervention, and involving them as collaborative partners in the assessment, intervention and management process, is not always clear to the parties concerned: child, parent, therapist and policy maker. Against a background of common practice (McLeod & Baker, 2004), the nexus between therapists’ beliefs and practice (Watts Pappas, McLeod, McAllister & Daniel, 2006), and what the evidence-base would encourage us to do (Baker & McLeod, 2011a, b), what is the Australian experience of family-centred practice in the area of children’s SSD?
A30. Nicole Watts Pappas: The Australian experience of family-centred practice in intervention for speech impairment History of parental and family involvement in speech intervention What is considered ‘best practice’ in working with parents and families in paediatric intervention has undergone significant changes over time. Traditionally, parents were given limited opportunity to be involved in their child’s speech intervention with services planned and delivered by the SLP/SLT in a therapist-centred approach to management (Crais, 1991). In the late 1970s and 1980s, SLPs/SLTs and other allied health professionals were encouraged to increase parents’ participation in intervention, primarily by requesting them to complete home activities with their child (Bazyk, 1989). However, parental involvement in these activities tended to be expected rather than optional and parents continued to have limited involvement in service planning and decision-making.
More recently, a new philosophy of working with parents and families, family-centred service, has been recommended as best practice (Rosenbaum, King, Law, King & Evans, 1998). Family-centred practice promotes the formation of collaborative parent/ professional partnerships and acknowledges parents and families as the primary decision-makers regarding their child’s intervention (Bailey, McWilliam & Winton, 1992). In addition, based on the theory that change to one family member will affect all other family members, family-centred practice considers the whole family as client rather than just the child.
Typical practice of parental involvement in speech intervention While recommended models for working with parents and families in SLP/SLT practice have changed, the practices of clinicians may not have undergone a corresponding transformation. The well-documented researcher/practice gap highlights the fact that clinicians may take time to incorporate new models of service into their clinical practice (McLeod & Baker, 2004). Three Australian studies have investigated how SLP clinicians involve parents in intervention for speech impairment. A survey conducted by McLeod and Baker (2004) of the speech intervention practices of 270 SLPs found that 88.2% of respondents reported they involved parents in their intervention for speech impairment. However, this involvement appeared to occur predominantly in intervention provision rather than planning – when asked about factors they considered when selecting treatment targets only 49.6% of respondents indicated they considered parental preference as a high priority.
In a more comprehensive study, Watts Pappas, McLeod, McAllister and McKinnon (2008) surveyed 277 SLPs regarding their beliefs and practices of parental involvement in speech intervention. The results of the survey indicated that the vast majority of respondents involved parents in some way in their intervention for speech impairment. The most common form of involvement was the provision of home activities with 95% of respondents indicating they always or usually provided home activities to parents. Other typical forms of involvement included parental attendance at assessment (84%) and intervention (80%) sessions. The SLPs reported using family-centred practices such as considering parents’ time and priorities when providing home activities (94%). However, the respondents did not use other family-centred practices as frequently. For example, only 44% of the SLPs indicated they allowed parents to choose the extent of their involvement in the intervention and only 17% always or usually gave parents an option regarding the service delivery format provided to their child. Parental involvement in intervention planning occurred less frequently than some other forms of involvement; 67% of the SLPs reported they involved parents in goal-setting; however, only 38% always or usually allowed parents to make the final decisions about intervention goals and activities.
A more recent study of parental involvement in speech intervention investigated the frequency and nature of parental involvement from the perspectives of the parents. Ruggero, McCabe, Ballard and Munro (2012) explored, through the use of an online survey, the experiences of 154 parents accessing speech pathology services for their child. Fifty-four percent of the children of the parents in the study were identified as receiving intervention for an SSD. The results indicated that while 76% of parents were asked to do homework activities with their child, only 43% were involved in goal-setting.
The results of these studies of the typical practice of SLPs indicate that although parents are usually involved in speech intervention services, the SLP retains primary control over the direction of the intervention, in a therapist-centred rather than a family-centred approach to management. However, a gap may be present between SLPs’ typical practice and their beliefs about what constitutes ideal practice, especially if barriers to using ideal practice exist.
SLPs’ beliefs regarding parent and family involvement in speech intervention Two studies have investigated Australian SLPs’ beliefs regarding parental and family involvement in intervention for speech impairment. The previously described study conducted by Watts Pappas and colleagues (2007) also investigated the SLPs’ beliefs with regards to parental involvement. We found in this study that the overwhelming majority of respondents (98%) agreed or strongly agreed that parental involvement is essential for speech intervention to be effective. The SLPs also believed that parents should be present at (78%) and participate (97%) in intervention sessions. However, 40% of respondents indicated they were not happy with the level of parental participation in their service or aspects of their service. In open-ended questions the SLPs reported the presence of various barriers that they believed prevented them from giving what they considered ‘ideal’ services to the parents they worked with. These included workplace barriers (such as working in a school setting), parent barriers (such as parent time, skills and inclination to be involved) and personal barriers (such as a lack of knowledge and confidence in working with parents in intervention for speech impairment).
Similar to the findings of other studies of professionals’ perceptions of working with families (Bruce et al., 2002; Litchfield & MacDougall, 2002; Minke & Scott, 1995), although the SLPs held a strong belief in the importance of parental involvement in intervention provision , they generally supported a more therapist-centred (as opposed to a family-centred) approach to management in the area of intervention planning and decision-making. For example, only 42% of the SLPs indicated that they agreed that parents should have the final say on the content of intervention goals and activities.
Why did the SLPs’ reported beliefs and practice support a more traditional approach to working with parents and families than is recommended by the literature? A second, more in depth study of the beliefs and practices of Australian SLPs addressed this issue. Watts Pappas and McLeod (2008b) conducted a focus group of six SLPs working with children with speech impairment. The focus group discussion centred on parental and family involvement in speech intervention and parent/professional relationships. The findings of the analysis of the group interview indicated that the SLP participants believed strongly in the importance of parental involvement in speech intervention and attempted to engage parents and families in their child’s intervention as much as possible. They also believed in providing respectful and supportive service to families. However, similar to the results from the survey, although the SLPs felt that parental involvement in intervention was critical, they also held a strong belief that the professional should make the final decisions regarding intervention planning and provision.
Several factors may have contributed to this belief. The SLPs considered themselves as the specialists in intervention for speech impairment. As the specialists they felt it was their role and responsibility to take the lead in the management of speech intervention. In addition, the participants in the focus group believed that parents both wanted and needed guidance from their SLP. Considering the complexity of intervention for speech impairment, the SLPs felt that parents did not have the skills to have the final say about intervention. Indeed, adopting parents’ choices for goals was postulated as an ethical issue if parents requested goals or activities that were contraindicated for the child.
With the current focus on efficiency and accountability in paediatric intervention services, SLPs are under pressure to ensure their intervention is evidence-based and effective (Reilly, 2004; Roddam & Skeat, 2010). Most evidence-based speech intervention approaches require specific choices regarding treatment targets or intervention activities (Baker, 2006). These approaches may be difficult to provide if parents insist on alternative goals and activities. The literature and policy makers have promoted family-centred practice as best practice in intervention for young children (Crais, Poston Roy & Free, 2006), but there is little evidence of its impact on speech intervention outcomes or its acceptability to parents is available. Only one study to date has investigated the effectiveness of a family-centred versus a therapist-centred approach to intervention for SSDs. McKean, Phillips and Thompson (2012) conducted a study of 20 children receiving intervention for speech impairment. Ten of the children received intervention incorporating family-centred principles; the remaining ten children received what was termed as ‘usual practice’. The outcomes of the study indicated that the family-centred condition did not lead to greater treatment gains. Considering the lack of evidence for family-centred practice, SLPs/SLTs may be reluctant to use this approach when it contravenes other demands of their workplace such as providing service that is evidence-based and efficacious.
Parents’ beliefs regarding parent and family involvement in speech intervention Contrary to the recommendations of best practice, the studies that have investigated parental involvement in speech intervention in Australia have indicated that SLPs’ beliefs and practice are not supportive of a truly family-centred model of service, particularly in relation to decision-making. However, a progressive in-depth study of the views of seven parents accessing speech intervention for their child (Watts Pappas & McLeod, 2008a) indicated that Australian parents might not necessarily want a family-centred approach to intervention for their child with speech impairment. The analysis of the interviews indicated that the parents believed that it was a SLP’s role and responsibility to both work with their child in the intervention sessions and to provide guidance about intervention goals and activities. If the parent trusted their SLP they felt the best thing they could do for their child was to follow the SLP’s lead in the intervention process. Comparably, Ruggero et al. (2012) found that involvement in goal-setting was not a contributing factor in parental satisfaction with intervention. Similar beliefs and expectations about parent/professional roles have been reported in other studies of parents’ perceptions of paediatric allied health intervention (Glogowska & Campbell, 2000; Leiter, 2004; MacKean, Thurston & Scott, 2005; Mirabito & Armstrong, 2004; Thompson, 1998). While the parents felt that their involvement in their child’s intervention (particularly the provision of home activities) was important, they wanted their SLP to take the lead role in intervention provision and planning and preferred intervention to focus on their child rather than their family.
Summary SLPs/SLTs believe strongly in parental participation in speech intervention and, within a background of various barriers to family involvement, strategise to engage families as much as possible in the process. They also attempt to provide respectful and supportive care to families and consider their needs and wishes in intervention planning. Allowing parents to take the lead in intervention planning and delivery however poses a dilemma for SLPs/SLTs, especially when parents’ wishes are at odds with the demands of EBP. While SLPs/SLTs consider the child within the context of their family, it appears that clinicians, as well as parents prefer an approach to intervention for speech impairment that is SLP/SLT-led and also predominantly child focused.
In a survey of SLPs (Hodge, Salonka & Kollias, 2005), clinicians in Alberta, Canada were asked about their use, and the roles and benefits as they saw them, of NS-OME in the treatment of children with speech disorders. Like Lof and Watson (2008), who analysed survey responses from 537 US SLPs and found that 85% used NS-OME to target speech, the Canadian researchers found that 85% of 535 Albertan respondents used NS-OME for the purpose of changing speech sound production.
Dr. Megan Hodge is an SLP and professor emerita in the Department of Speech Pathology and Audiology at the University of Alberta, where she directs the Children’s Speech Intelligibility Research and Education (CSPIRE) laboratory. She has taught in the areas of anatomy and physiology of the speech mechanism, speech science and motor speech disorders. Her research interests include developmental aspects of normal and disordered speech production, perceptual-acoustic correlates of speech intelligibility and linking theory with practice in evaluating and treating children with motor speech disorders. Currently she is engaged in several collaborative projects with community partners to create care pathways to improve services and outcomes for children with complex speech disorders. In her response to Q31, Dr. Hodge discusses the survey results and their implications, providing an informed view of common practice in at least one Canadian province, and effective practice as it is taught in Canadian universities.
Q31. Megan M. Hodge: A Canadian perspective on oral motor exercises What insights do the results of the 2004 survey of Albertan SLPs’ use of NS-OME in children’s speech therapy reveal about common clinical practice, compared with effective practice as taught in Canadian universities?
A31. Megan M. Hodge: What can we learn about clinical practice from SLPs’ experiences using NS-OME in children’s speech therapy? Information about the survey conducted by Sophie Kollias and Robin Lester (2004) under my supervision is followed by conclusions from our research. After each conclusion, I comment on (a) what it might reveal about clinical practice for childhood SSDs, (b) how this relates to my knowledge about effective practice as taught in Canadian universities and (c) what I see as the implications to address the evidence-to-practice gap for SLPs serving Canadian children with SSD.
The survey results represented responses from approximately 28% of SLPs registered with the Alberta College of Speech-Language Pathologists and Audiologists (ACSLPA) who provided speech therapy to children (0– 16 years of age) during June 2004. The survey collected information about respondents’ opinions and experiences using NS-OME. We do not know how representative the sample is of Albertan or Canadian SLPs who use NS-OME so these results cannot be generalised to all SLPs. However, they represent a range of responses from a substantial sample of SLPs. It is also important to understand that the purpose of this survey was not to describe common practice for children with SSD; rather, it addressed use of NS-OME in children’s speech therapy. Eighty percent of survey respondents served children between birth and 8 years; 30% worked in schools, 25% in community health centres, 18% in private practice, 16% in early education settings, 8% in hospitals and 3% in other settings. The majority of respondents (67%) had more than 5 years of clinical work experience.
Conclusion 1 For the 85% of respondents who reported using NS-OME with at least one child between 1999 and 2004, the most common practice was to use NS-OME in therapy as warm-up activities, as part of a speech goal, and/or assigned for home practice. The three most common therapy objectives identified for using NS-OME were to increase articulator strength and coordination, facilitate stimulability for consonants and vowels and improve speech intelligibility. Respondents’ reasons for using NS-OME were their beliefs that NS-OME were effective or that no other intervention had worked. When NS-OME were used, 56% of SLPs reported spending from 5 to 15 minutes performing these exercises in therapy, while 31% spent less than 5 minutes. However, some SLPs reported using NS-OME for an entire treatment session and, in a few cases, not as part of a speech goal (e.g., to decrease drooling, improve feeding skills, strengthen muscle groups unrelated to a specific articulation goal).
Comment ‘Warm-up’ activities in speech therapy sessions, assigning NS-OME as home practice activities and training articulator strength are not presented as EBPs for childhood SSD in Canadian university training programs. Clark (2010) concluded that ‘much more extensive and higher quality treatment literature is needed to determine the conditions under which OMEs are most beneficial as well as the therapeutic mechanisms underlying their effectiveness’ (p. 579). Information that is available in NS-OME materials appears useful to SLPs in stimulating production of difficult to elicit sounds. Scholarly publications such as Secord, Boyce, Donohue, Fox & Shine’s (2007) Eliciting Sounds: Techniques and Strategies for Clinicians are useful resources for students and clinicians. In some cases, this may involve using tools such as bite blocks to stabilise the jaw, allowing the child to experience articulatory movements of the tongue and lips that are independent of the jaw (Hodge, 2010).
Conclusion 2 In general, developers of NS-OME advocate their use for improving speech intelligibility in individuals with various communication disorders (e.g., Chapman Bahr, 2001; Rosenfeld-Johnson, 2001, 2010). Published peer-reviewed original research does not exist currently to substantiate or unequivocally discredit these claims (Clark, 2010). Not surprisingly, survey respondents reported using NS-OME most often for children with phonology/articulation delay/disorder (37%), suspected childhood apraxia of speech or CAS (33%) and dysarthria (15%). Answers to open-ended survey questions suggested that (a) respondents have children on their caseloads with these diagnoses that are challenging to treat and NS-OME seem to be helpful in some cases, and (b) the prescriptive treatment offered by NS-OME allow SLPs to be ‘time efficient’. Many clinicians stated that they use whatever technique works for them (including NS-OME), or that NS-OME are a place to start when they do not know what else to do. NS-OME appeared to be used most commonly for clients with syndromes and medical conditions that typically result in concomitant difficulties producing intelligible speech, such as Down syndrome and cerebral palsy. Possible reasons for the higher frequency of NS-OME with these syndromes and conditions include (a) developers of NS-OME often ‘market’ their use for these children, (b) NS-OME provide a step-by-step approach for children with more complex speech disorders and challenging speech intelligibility problems and (c) intuitively it may make sense to use motor exercises in therapy because children with these conditions have difficulty controlling the oral musculature as part of their impairment (see Clark, 2003; 2010, for discussion about why this ‘intuition’ needs careful examination).
Comment SLPs appear most likely to use NS-OME in treatment for children who (a) appear to have a motor component to their speech disorder and do not benefit from traditional articulation therapy approaches, and/or (b) present with a severe and complex SSD. Canadian university training programs are heterogeneous in how they teach students to diagnose and treat children with SSD that have a suspected or known motor component (i.e., CAS, dysarthria, mixed CAS-dysarthria). ASHA’s (2007) position statement standardises basic information about CAS for students and professionals, provides guidelines for treatment that explicitly exclude NS-OME, and highlights the need for treatment research. As an alternative to NS-OME, Davis and Velleman (2008) proposed a ‘means, motive and opportunity’ conceptual framework to establish a speech repertoire in children with severe speech delay. Their framework focuses on stimulation of meaningful vocalisations for functional communication, which is validated by the early language development literature. There is a very small but growing body of research about effectiveness of speech-based interventions for children with dysarthria (e.g., Pennington, Miller, Robson & Steen, 2010; Pennington et al., 2012). My experience is that most Canadian universities currently provide minimal information about speech therapy practice for this population of children. Development and dissemination of current best practice guidelines and development and evaluation of therapy programs for children with motor speech disorders, which include clinicians as collaborators, are obvious needs in Canada. The care pathway for managing pre-school children with suspected CAS presented by the Ontario Ministry of Children and Youth 2010 Working Group for Children with Suspected Motor Speech Difficulties (OMCY-2010WG) (April, 2011) is an example of an initiative that addresses this need. Based on the lack of research support and questionable theoretical constructs for using NS-OME for children with speech difficulties, the Working Group also recommended that NS-OME be considered an alternative treatment approach, governed by the College of Audiologists and Speech-Language Pathologists of Ontario’s position statement for Alternative Approaches to Intervention (B. R. Gaines, personal communication. April 19, 2013.) This requires that clinicians who intend to use NS-OME obtain informed consent from parents.
Conclusion 3 Users of NS-OME indicated that they were influenced by the high degree of exposure to NS-OME products and materials (e.g., products marketed by Rosenfeld-Johnson, 2001, Super Duper Publications, LinguiSystems and www.pammarshalla.com ), and clinical success (self and reported by colleagues).
Comment SLPs’ responses reveal the weight put on knowledge of products gained through ‘marketing’ exposure and that of their own and colleagues’ experience in influencing their practice. All Canadian training programs aspire to graduate SLP professionals who can think independently and critically. Concerted, focused efforts are needed to foster and develop these skills in coursework and clinical placements so that graduates are informed, judicious consumers of products in the marketplace and colleagues’ advice. As noted in the comments for Conclusion 2, many survey respondents who used NS-OME reported using them with children suspected to have a motor speech disorder and/or presenting with a severe and complex SSD. We need to increase the number of graduates who are knowledgeable and confident about practice for these subgroups of children. There also appears to be a disconnect between what is presented as effective practice in Canadian training programs and what information is presented by invited speakers and marketed by exhibitors at professional conferences and professional development events. Sara Rosenfeld-Johnson has been an invited speaker at several conferences hosted by professional associations in Canada. Greater communication and collaboration between Canadian academic training programs and national and regional professional conference committees to promote and debate best practices in SSD appear warranted.
Conclusion 4 Survey respondents were asked if they have seen significant changes in clients’ speech because of NS-OME and, if so, to describe the changes observed. Those who answered ‘yes’ typically stated that NS-OME improved the strength/coordination of articulators as well as overall speech intelligibility or resulted in stimulability of speech sounds and improved production of particular sounds classes (i.e., rhotics and sibilants). Respondents who reported variable results stated that NS-OME helped with stimulability/awareness or strength/coordination of the articulators, but were ineffective with certain children and that some NS-OME programs were not as effective as others. A strong theme that emerged was that NS-OME are useful with certain children but they are not meant for everyone. Many respondents explained that NS-OME have a small role in a therapy session, and are not the sole treatment strategy. Other treatment approaches mentioned were traditional articulation therapy, Hodson’s cycles, phonological processes, minimal pairs, phonetic placement, auditory discrimination, visual feedback, multiple opposition, maximal opposition, non-linear, PROMPT, rate reduction, whole language and total communication that incorporates some form of AAC. However, a small subgroup of respondents appeared to use NS-OME for many clients and disorders and believed that NS-OME produce effective changes in multiple areas. The majority of respondents rated the evidence base for NS-OME as minimal or non-existent (64%). Surprisingly, 36% of the 137 respondents rated the evidence as adequate or extensive. While only 36% of respondents thought there was evidence to support NS-OME in SSD, 50% claimed that NS-OME have an important role in children’s speech therapy. Obviously, some clinicians who do not think there is evidence to support the use of NS-OME believe that they have an important role in speech therapy. Many respondents commented that they would like to see research investigating the benefits of NS-OME.
Comment The survey results revealed that Canadian SLPs are heterogeneous in their beliefs and practices about using NS-OME for treating children with SSD and use an eclectic and pragmatic approach to speech therapy. Experience/exposure, training and available resources were common responses for why SLPs do or do not use NS-OME. Some SLPs firmly believe that NS-OME are effective in improving children’s speech based on their clinical experience. Other SLPs do not see any benefit from NS-OME and will not use them without research-based evidence. The majority of SLPs surveyed fell between these two positions.
Summary In summary, the role of NS-OME in children’s speech therapy is an example of a complicated issue for which SLPs need and desire clearer guidance. Clark (2010) encouraged clinicians who use NS-OME to contribute well-designed single subject studies that use measures of both speech ability and the physiological mechanisms addressed by the NS-OME used (e.g., strength).
Although these survey results were obtained in 2004, they still provide several hypotheses to test in research about clinical use of NS-OME in SSD. For example, ‘Do NS-OME improve strength and coordination of the articulators and do these improvements increase speech intelligibility?’ and ‘Are NS-OME more effective at increasing speech intelligibility than treatment approaches where NS-OME are not used?’
The results of this project also revealed gaps in knowledge that Canadian SLPs have about treating certain children with SSD. However progress is being made. Canadian academics and clinical researchers are generating and disseminating research evidence (e.g., Rvachew & Brosseau-Lapré, 2012), helping SLPs to locate and translate evidence to practice for children with SSD (Johnson, 2006) and influencing policies for services for children with SSD (Hodge, November, 2011; OMCY-2010WG, April, 2011). Our training programs and professional associations advocate and support EBP and SLP managers and policy makers are expressing their desire to do so (e.g., Robertson, 2007). Major continuing challenges in the Canadian context include scarce research dollars for treatment research for SSD and limitations on public funding for clinical services.
With a population of fewer than 4.5 million inhabitants New Zealand is a young and remarkable country that consistently punches above its weight in areas as diverse as adventure tourism, film and television, human rights, science and speech-language therapy.
Dr. Gail Gillon (Ngāi Tahu iwi) (ASHA Fellow) is Pro-Vice-Chancellor of the College of Education at the University of Canterbury in Christchurch, New Zealand. A professor in speech-language therapy, Dr. Gillon has been involved in writing best practice documents relating to speech and language therapy services for school-aged children for the New Zealand Ministry of Education. Her own research work has focused on enhancing the literacy success of children with speech and language impairment in the New Zealand pre-school and primary school educational context. Professor Gillon discusses effective practice within a New Zealand context and issues facing new graduates from SLT university programs as they blend into the reality of the education workplace.
Q32. Gail T. Gillon: New Zealand Speech-Language Therapy and Education What is the relationship between the SLT academic community and education community in New Zealand given the profession’s historical development from an educational context? What are some of the challenges facing SLTs working in educational contexts in New Zealand in terms of meeting ‘best practice’, and how may these challenges best be addressed?
A32. Gail T. Gillon: New Zealand SLT: partnerships between the academic and educational community The successful management of childhood speech and language disorders has been a dominant theme in the history of speech and language therapy within New Zealand. The education of New Zealand SLTs grew from a teacher education context. Christchurch Teacher’s College established the first tertiary education course for SLTs in 1942, with a 1-year intensive diploma course that followed a 2-year training program in teacher education.
Over time, the education of SLTs in New Zealand expanded to reflect the increasing scope of practice in the discipline and to ensure that graduates could serve the needs of both adults and children with communication and swallowing disorders. The University of Canterbury in Christchurch first offered a 4-year Bachelor of Speech and Language Therapy degree in 1989 and continues to offer this degree alongside Master’s and PhD research degrees in speech-language therapy. In 2003, Massey University began a 4-year Bachelor of Speech-Language Therapy degree program at its Auckland Campus and the University of Auckland now offers a 2-year Master’s Degree in Speech and Language Therapy Practice.
All three providers of SLT education in New Zealand are committed to ensuring that graduates are well qualified to manage communication and swallowing difficulties across the lifespan, and their graduates readily gain employment with a variety of employers in the health, education and private sectors. However, the relationship with the Education sector and the profession of SLT and, in particular, the New Zealand Ministry of Education continues to be robust.
The Ministry of Education is one of the main employers of SLTs in New Zealand. Through its Special Education Division, its SLT services concentrate on children who have significant communication impairments. In its endeavours to ensure that this population is well served, the Ministry commissioned a ‘best practice’ report of SLT assessment and treatment practices for children aged 5–8 years with speech and language disorders in 1998 and commissioned updates in 2001 and 2006 (Gillon & Schwarz, 1998, 2001a; Gillon, Moriarty & Schwarz, 2006). Policy makers and budget holders in education rightly asked fundamental questions about the delivery of SLT services for children in New Zealand Schools, including:
What are the most valid and reliable assessment methods for identifying children who are in need of SLT services? What is the best method to treat a particular type of childhood speech and language disorder? How much treatment time is required to resolve a particular disorder? What are the most cost effective methods to address the needs of young children with communication disorders? How can the needs of young Māori (New Zealand indigenous population) be best met, particularly for those children with speech-language needs who are being educated in Māori immersion education environments? Addressing the last question has been particularly emphasised in recent years. To respond to the academic underachievement identified for Māori children in the education system, the New Zealand Ministry of Education introduced, in 2008, Ka Hikitia ; a strategy aimed at ensuring Māori students enjoy education success as Māori. Phase 2 of this strategy, Ka Hikitia: Accelerating Success 2013–2017, has recently been released (Ministry of Education, 2013). In 2009, over 28,000 Māori students were being educated in Māori medium education programs (i.e., either all or some curriculum subjects were taught in the Māori language) and statistical forecasts for the New Zealand population show that by 2030 the proportion of school-aged children who are Māori is likely to increase to around 30%. It is important for SLTs working in New Zealand to understand culturally responsive practices in working with Māori children, their teachers and their families.
Answering questions regarding best practices, cost efficient practices and culturally appropriate practices is not straightforward (Goldstein, A19; Zajdó, A20). The complexities of communication development and cultural influences from diverse populations result in there being no single assessment tool or intervention program that is recognised as universally effective for all children with speech or language impairment. Rather, SLTs must use a range of assessment measures and plan intervention that is specific to a child’s needs, including educational needs, and is sensitive to the child’s cultural and family environment (Watts Pappas, A30). The intervention approach selected needs to be appropriate to the type and level of severity of the child’s communication impairment and must foster both spoken and written language abilities and the prerequisite skills for successful reading and writing development.
Understanding effective or best practices for children based on research evidence is of fundamental importance to the advancement of the SLT profession. The claim made by some practitioners that an intervention method is adopted clinically ‘because it works’ has been challenged (Gruber, Lowery, Seung & Deal, 2003). More powerful justification for an intervention decision than clinical perception is required (Hodge, A31; Powell, A39). The many confounding variables that influence the perception of intervention effectiveness necessitate the use of well-designed research studies to demonstrate an intervention method is causing the positive changes observed in children’s communication development.
Thus, the profession of SLT is being challenged to be more accountable for the services provided to children with communication impairment and to ensure services are educationally relevant and culturally and linguistically appropriate. Service providers need to have confidence that assessment and treatment methods implemented with children are grounded in research and theory, validating their use. Therapists need to demonstrate the effectiveness of their services for diverse populations, and within a limited resourcing funding model for SLT, the cost efficiency of the services must also be considered.
The challenges of providing effective, cost-efficient services for children with communication impairment occur in a context of increasing demand for services. The need for childhood SLT services in New Zealand is undeniably high. The New Zealand Government’s educational strategy places a strong emphasis on enhancing literacy success and improving academic achievement for all New Zealanders. A core element of literacy and academic success is proficient reading ability. Although New Zealand continues to enjoy an above average overall reading standard at an international level, there are areas of significant concern that warrant urgent attention. For example, children in New Zealand who enter school at 5 years of age with low ‘literate cultural capital’ (low levels of phonological awareness (PA), grammatical sensitivity, receptive vocabulary, and letter knowledge), frequently children from low socioeconomic areas, continue to demonstrate poor reading achievement in year 7 (Tunmer, Chapman & Prochnow, 2006). Tunmer et al. concluded from their longitudinal study, which followed 76 children from 5 to 11 years of age, that the current language curriculum and standard reading interventions provided in New Zealand schools do not adequately address the needs of children who enter school with low language abilities. This suggests that either the curriculum or the methods of reading instruction require modification or new interventions need to be implemented to enhance these children’s development in the early school years. SLTs’ expertise and scope of practice suggest that they have a critical role in supporting and collaborating with teachers to ensure that the language needs of young children are being enhanced within their classroom learning (Neilson, A22).
Of fundamental importance to literacy and academic success is strong oral language development. Gillon and Schwarz (2001b) developed and administered a screening test to explore critical spoken language skills for academic success in 6-year-old children in New Zealand. The screening test measures articulation, receptive and expressive language and PA. A total of 952 children were screened across the country, with children with any type of diagnosed disorder that would influence speech or language development excluded from the study. The results indicated that as many as 18% of the children warranted in-depth assessment of their spoken language skills. Consistent with Tunmer, et al.’s (2006) findings, the study indicted those children from schools in low socioeconomic areas and Māori children were over-represented in the at-risk group.
Provision of SLT services needs to expand to ensure adequate resourcing for SLTs to work with educators in early intervention and preventative roles. Subsequent reading and writing difficulties experienced by young New Zealand children identified as being at risk due to delayed or disordered spoken language development can be prevented with appropriate intensity levels of intervention and intervention focused on building underlying skills critical for literacy success (Carson, Gillon & Boustead, 2013; Gillon, 2000, 2002, 2005). Funding of SLT services must be at a sufficient level to ensure that research-based interventions can be implemented when appropriate to meet individual children’s needs.
A further challenge for the educational community is raising literacy achievement for boys. A recent international literacy study documenting reading comprehension performance of fourth-grade children (average age 9;6) in 45 countries (Progress in International Reading Literacy Study, PIRLS, 2011; Mullis, Martin, Foy & Drucker, 2012) indicated that boys are achieving significantly lower than girls in literacy at an international level. In nearly all of the countries, girls outperformed boys, and there has been little reduction in the reading achievement gender gap over the last decade. In New Zealand, the difference between boys’ and girls’ reading comprehension performance was more marked than in many other countries such as Italy, France, Germany, USA and Canada, but similar to the difference between boys and girls reading comprehension abilities in Australia, England and Finland. Mirroring these data clinically, SLTs typically have many more boys on their caseloads than girls, and the relationship between early speech and language difficulties observed in boys and their academic achievement needs to be further explored.
Challenges are frequently best addressed through collaborative efforts. The current challenges in meeting the needs of children with speech and language impairments require enhanced meaningful relationships between various communities. Partnerships between universities (or the providers of SLT and teacher education), school and family communities, government bodies in policy and funding services and appropriate cultural and ethnic groups need to be well established. Such collaborations must be directed towards a common goal of ensuring that every child meets his or her educational, social and cultural potential to contribute to their society in positive ways.
The New Zealand education system provides a strong context for collaborative efforts between SLTs and teachers to flourish. The PIRLS 2011 study (Mullis et al., 2012) also investigated teaching contexts and how teachers work together. Teachers in the middle schools years frequently favour collaborative teaching practices and in New Zealand primary school children are more likely to have been taught by ‘very collaborative’ teachers than many other countries.
Maintaining meaningful partnerships between universities and the education community is an area of particular importance. In New Zealand, all providers of SLT training are in universities that have a strong research orientation. Academics teaching in SLT education programs are expected to conduct research in areas of relevance and importance to their discipline. Robust, scientific models of research using both quantitative and/or qualitative designs are embraced. Effective partnerships between the academic communities of SLT (as well as other relevant academic disciplines, such as audiology, education, linguistics and psychology) will help facilitate the transfer of knowledge from research to the practice of SLT.
As with all good partnerships, trust and respect between the academic communities of SLT and the educational community are vital. The knowledge of the researcher and the knowledge of the practitioner need to be understood and equally respected. Ethical responsibilities in conducting human research must be of paramount importance, yet a balance between protecting children, families and school communities and potentially restricting most forms of science-based research needs to be reached. The practitioners must trust the researcher to act in an ethically responsible manner and adopt methodological procedures approved via robust ethical clearance processes. The researchers need to trust practitioners involved in research studies to implement research protocols as agreed, to maintain confidentiality, and to adhere to standard research procedures. Developing vigorous partnerships in research where both practitioners and researchers in SLT and teacher education contribute to the advancement of knowledge is essential, to address the challenges faced by our profession.
Through partnerships, the practical implications of the research can be more adequately addressed. Consideration of a number of factors is important in deciding whether it is appropriate for the latest research findings to be immediately integrated into clinical or teaching practice (Ingram, 1998). The depth of the research body, the quality of the research methodologies employed and treatment fidelity measures, the relevance of the findings to a specific clinical population, the practicalities of implementing an assessment or intervention technique explored under ideal research conditions into a school setting and the appropriateness of the intervention to a child’s cultural, family and educational environment all influence the transfer of research knowledge to practice.
The small population base and geographical size of New Zealand is conducive to facilitating relationships at regional and national levels. Indeed, historically, there have always been strong and close affiliations between the academic and professional community in SLT and New Zealand educational communities both from a teaching and research perspective. Maintaining and further enhancing these partnerships will be critical as we move forward in the 21st century in successfully addressing the needs of individuals with communication impairments.
In A4, Mirla Raz, an SLP clinician in Arizona with over 40 years’ experience in private practice and school settings, was cautiously optimistic about the potential for tablet computers and application software (Apps) to enhance the delivery of speech assessment and intervention. At the same time, she pointed to a number of technical shortcomings that currently limit their usefulness as clinical tools. By contrast, when I first heard the next contributor talk about information and communication technology (ICT), tablet computers and Apps it was apparent that, as a speech and language clinician, she embraced their use more wholeheartedly than Raz. Indeed, she wrote, ‘the use of Apps and technology has revolutionised how I can and do provide intervention’ (Kylie Toynton, personal communication, 2013).
Mrs. Kylie Toynton graduated as a speech pathologist in 2000, and was awarded a Master’s degree in Gerontology in 2012. After 12 years in the public sector, Mrs. Toynton is engaged in private practice in a rural Australian location near the small country town of Coonabarabran, NSW. She provides SLP/SLT services to a general paediatric caseload in settings that include early intervention Aboriginal children’s services, pre-schools, schools, special education and early education. Her professional interests include the classroom use of technology, access to SLP/SLT services for rural and remote clients, the suitability of Apps and other technology for indigenous Australian and low-income populations, parent and community education regarding technology options and access to ICT in urban centres.
Q33. Kylie Toynton: A rural Australian view of ICT and Apps in SSD Technology and speech-language pathology are frequent bedfellows. But, for the SLP/SLT who is interested in EBP the bed can be a little uncomfortable. Numerous developers of downloadable worksheets, Apps, online games and other technological offerings have quickly risen to the challenge of developing attractive, inexpensive resources for clinicians to use when working with children with SSD. In this rapidly expanding niche market, some are marketed primarily to clinicians who have welcomed them with enthusiasm. As well, many if not most are presented as useful tools for parents and teachers to purchase too, to use as well as or instead of SLP/SLT intervention, for children with articulation disorders, phonological disorders and CAS. Unrelenting social media recommendations, online discussion and advertising of Apps and devices mean that clients will often come with questions about them, including questions about their effectiveness. As an ethical SLP in a rural setting, how do you make sense of all of this and guide clients and colleagues towards productive choices? How do you utilise child speech related technology, and what might the future hold?
A33. Kylie Toynton: Technology and SSD: navigating new pathways, keeping best practice The vast array of ICT available to SLPs/SLTs may offer the potential to allow us to work more efficiently and at a greater geographical distance from our clients. SLPs/SLTs have embraced ICT even though the rapid increase in technological development has not been associated with a corresponding increase in an evidence base to support its application in clinical settings. This gap creates a difficulty for the clinician pursuing the ideal of evidence-based practice (E3 BP, Dollaghan, 2007). While many SLPs/SLTs and consumers are aware of the range of technology available, we need to educate others and ourselves on how best to implement what is on offer to meet our clients’ goals (Meredith, Firmin & McAllister, 2013).
ICT affords more service delivery options in the form of telehealth and computer aided intervention. It has created stronger professional connections that allow national and international communication and knowledge sharing, between new and more seasoned colleagues, through the use of Skype, Twitter and other social media (Davis, 2013). Two questions arise regarding children’s SSD: Does ICT help in their assessment and treatment, and do tablet computers and their Apps enhance intervention outcomes?
Assessment Apps may be useful to reduce time spent analysing assessment data. Although this may be an attractive feature for overstretched SLPs/SLTs, speech assessments need to be valid and reliable (Joffe, A34, Skahan, Watson & Lof, 2007, p. 252). The Sunny Articulation Phonology Test 1 Bilingual Articulation Phonology Assessment: English/Spanish (Smarty Ears LLC, 2012) and Articulation Screener Pro (Synapse Apps LLC, 2012) make provision for calculating percentage consonants correct (PCC), doing an intelligibility rating, recording the error-types substitution, omission, distortion and additions and phonological process analysis covering backing, cluster reduction, consonant deletion, devoicing, fronting, gliding and stopping. Only one of the few Apps currently available for child speech assessment the LinguiSystems Articulation Test (LinguiSystems Inc., 2012) is standardised. It has associated reliability and validity data, and results can be expressed as standard scores, percentile ranks and age equivalents. This is obviously problematic because it is not possible to create articulation tests with ‘more difficult words’ as the child’s age increases. This means that the bell curve that you can have in language testing where test items increase in difficulty, is impossible with articulation tests.
A growing number of Apps address intervention for articulation disorders, phonological disorders and CAS. Articulation Station , ArtikPix , Speech Sounds on Cue , Speech Tutor and Pocket Artic , are designed for traditional articulation therapy (Van Riper, 1978). Apps that incorporate minimal pair activities for children with phonological disorder include PhonoPix , PocketPairs and SLP Minimal Pairs . An App intended for drill practice for children with CAS is ApraxiaCards . All of the Apps mentioned have useful features to support intervention for children with SSD, but no one app can support all the activities an SLP/SLT might want to implement in a treatment session. Judicious selection of an App, or a combination of Apps, in conjunction with paper- or game-based activities can potentially meet both clinician and client needs.
Guiding parents In my clinical experience, parents want support and advice regarding purchase of tablet computers and Apps for their child with SSD. Apps can create an enjoyable learning environment for the child, potentially increasing the likelihood that they will engage in home practice (Toki & Pange, 2012, p. 278). I approach the role of a ‘technology advisor’ keeping in mind families’ different expectations, budgets and knowledge of ICT as exemplified when I was asked by the mother of Sasha, 6;0 to provide advice on the Apps to buy to complete home practice for /s/ and /.ɹ/. She wished to buy no more than three, and I suggested Speech Tutor , Speech Sounds on Cue and Articulation Station all cited above. Speech Tutor provides lateral cross-sectional and frontal views of the production of individual phonemes only, appealing to children from 4 years of age to adolescents, and those struggling to visualise correct production. The client’s sound production can be recorded and the playback speed can be adjusted to facilitate phonetic transcription. This App is valuable only in the phonetic placement (isolated sound stimulability) aspect of intervention. Speech Sounds on Cue provides videos of productions of sounds in isolation, words and short phrases, multiple cues for prompting correct production of the target and is available in a US English, a UK English and General Australian English (Cox, 2012). Whilst this App was developed for both adults and children, it is particularly suitable for use in the paediatric population with clear verbal prompts for sound production of individual phonemes and target phonemes in initial position in words with the accompanying visual cues and multiple presentations of the target. Although the child’s productions can be recorded and replayed during intervention, audio cannot be stored and there is no provision to record and keep client data within the App. This App is particularly useful in phonetic production training. Articulation Station offers photo flashcards to elicit production of consonants in all positions in words at word, sentence and story level suitable for children aged 4;0 and above. Individual and group data can be stored, as can audio data that has been recorded during therapy. The App allows for custom words and images to be uploaded to create personalised word lists. Verbal prompts are presented in Standard American English only, so families who are speakers of other varieties of English need to mute the device and present the cues ‘live’ to the child in homework sessions.
For the family of Thomas, 4;11 with a phonological disorder, Apps were not a homework option, as they did not own a tablet. However, his pre-school was equipped an iPad, a full-time aide to support the implementation of a speech program and a small fund for purchasing Apps. The pre-school asked me to recommend an App that might help him, and other children with speech difficulties. I recommended the purchase of PocketPairs that employs minimal pairs, with listening and production tasks, intended to target 12 developmental processes. The App offers diagrams of the oral cavity for placement, the capacity to store and graph client data and an across venue communication option using comment boxes. It can be used with individuals or groups with children 4;0 and above.
The Tomarakos (2012) App Review Rating Scale is a means of scoring and assigning a 1–5 star rating to speech, language and education Apps and users can elect to enter their rating on the App’s product page in the iTunes store. I used this tool to evaluate PocketPairs , giving it a 4-star rating (15/20).
My use of technology In my view, the use of Apps and other technology enhances my practice. That being the case, I use a tablet computer in every therapy session I conduct with children with SSD. I utilise technology to access information, and therapy tools and materials from multiple sources, with targets presented in multiple modalities. This enables me to conduct sessions that are motivating for child and parent, and evidence based. My practice is also enhanced through the use of Facebook, Twitter, Pinterest (a pin board style, photo sharing website), YouTube, and web-based resources such as LessonPix , and Tar Heel Reader .
I use Apps in a variety of other ways. I take advantage of timesaving tools like chronological age calculators, and torch Apps for oral examinations, voice recording Apps, popular game Apps for eliciting production of targets at sentence and conversational level. (Clausen, 2013). I also use document storage Apps like GoodReade r and EverNote for PDF’s of therapy materials.
Social media, used for professional purposes provides opportunities to network colleagues and experts worldwide in a way never possible before (Davis, 2013, p. 28). SLPs/SLTs specialising in SSD, organisations supporting children with SSD such as Childhood Apraxia of Speech Association of North America (Gretz, A7) and some professional journals have Twitter and Facebook accounts linking to information gateways. Online discussion such as phonological therapy group (Bowen, 2001) provides opportunities to ask questions and post information relevant to SSD. Finally, Pinterest is useful for finding, storing and organising ideas for therapy sessions and YouTube for ‘how to’ videos for new Apps or online programs. Web-based resources such as LessonPix allow quick and efficient creation of visuals for use in therapy sessions that can also be emailed to parents for home practice.
The range and immediacy of all these forms of information access help me to feel connected to a much larger community: a very important thing for a rural sole therapist. As well, it connects me to the evidence via professional learning communities (PLCs). PLCs created through social media sites allow SLPs/SLTs to seek the advice of experienced therapists (Davis, 2013, p. 13) and be directed to quality evidence in SSD by their colleagues.
Conclusion By the time A33 is published there will have been another wave of technological development. I believe that ICT will change our practice in the field of SSD in the areas of service delivery, intervention and professional development. Telehealth will become a familiar service delivery option as the technology that supports its advances. Online virtual worlds could become a method for training parents in SSD therapy techniques (Meredith et al., 2013 p. 45) while waiting for service or to supplement individual therapy (Ruggero, McCabe, Ballard & Munro, 2012). There will be increased availability of standardised articulation and phonology assessments and informal assessments to suit mobile devices (Limbrick, McCormack & McLeod, 2013, p. 306), and more intervention Apps. Specialty Apps that measure speech acoustics and allow for phonetic transcriptions of speech samples will become more refined. I believe that professional development opportunities will increase with the growth of PLCs via social media, and wider availability of webinars on demand filmed at live events and conferences.
Whether child-speech-related technology enhances intervention outcomes for children with SSD has not yet been studied. However, in my opinion ICT can increase participation and access to appropriate therapy for geographically or socially isolated clients; assist in engaging the ‘hard to reach’ child in intervention activities through motivating, varied presentation of therapy targets; and improve uptake of home programs by parents due to the universality of the computer/tablet platform. The choice and implementation of technology for each individual child, family and professional will always need to be based on a thorough assessment and the thoughtful selection of targets and goals. The onus of responsibility to do so will always come down to individual clinicians and their commitment to keeping up to date with the new developments and evidence.
Dr. Victoria Joffe is a specialist speech and language therapist and professor in developmental speech, language and communication impairments in the Department of Language and Communication Science at City University, London. She is program director of an MSc degree in Joint Professional Practice: Language and Communication run in conjunction with the Institute of Education, London (www.talklink.org ). Victoria obtained her DPhil degree in the Department of Experimental Psychology, The University of Oxford, exploring the relationship between oral language ability, metalinguistic awareness and literacy in language-impaired children. Her areas of clinical and research interest include specific language impairment, speech disorder, the interface between education and SLT, the relationship between language and literacy, narrative therapy and language impairment in secondary school age children. Victoria is currently involved in a large-scale intervention project funded by the Nuffield Foundation on enhancing language and communication in secondary school age children with language impairments (http://www.elciss.com ).
In research with a colleague at City University (Joffe & Pring, 2008), Dr. Joffe investigated the methods of assessment and remediation of ‘phonological problems’ used by therapists working in the United Kingdom. The surveyed therapists comprised 9 who were in their first year of practice, 25 with 1–3 years, 13 with 4–6 years, 13 with 7–10 years and 38 with more than 10 years of experience. These SLTs reported using a variety of therapies: auditory discrimination, minimal contrast therapy and phonological awareness were the most popular and were often used in combination. Most respondents reported involving parents, and, in planning therapy, clinicians were more influenced by children’s language and cognitive abilities and the motivation of parents than by the nature of the impairment. Probably the most striking outcome of this research was the information about assessment practices. Dr. Joffe talks about this in her response to Q34.
Q34. Victoria Joffe: Common practice in speech sound disorders in UK Reporting on a survey of child speech practice in the United Kingdom (Joffe & Pring, 2008), you wrote: ‘Constraints upon clinicians make it difficult for them to convert research findings to practice. In particular, assessments that allow more individualised and targeted interventions appear little used. Clinicians are aware of research but there is a danger that clinical practice and research are diverging.’ Of your 98 respondents, 83 (85%) used the South Tyneside Assessment of Phonology (STAP; Armstrong & Ainley, 1988) as a primary data source for planning speech intervention. Assessment with the STAP would provide only one small, non-standardised fraction of the relational analysis component of phonological assessment (Baker, 2004; Stoel-Gammon & Dunn, 1985), sufficient for intervention planning. Nonetheless, 77% of the respondents rated themselves ‘very confident’ or ‘confident’ in their ability to select therapies. A later survey (Pring, Flood, Dodd & Joffe, 2012) revealed similar practices and beliefs. Can you comment on these remarkable findings and reflect on the possible barriers, in the British context, between pedagogy, research findings and EBP?
A34. Victoria Joffe: Surveys of clinical practice in UK Around 61 /2 percent of all UK children have an SSD in the absence of any other cognitive, sensory or physical impairment (Broomfield & Dodd, 2004a). Such children typically dominate SLP/SLT paediatric caseloads (Gierut, 1998), and in Britain most receive treatment in community clinics or schools. Except for anecdotal accounts, little information exists about the practices of SLTs, and a dearth of information around the relationship between practice and outcomes constitutes a serious gap (Kamhi, 2006b). In Joffe, 2009, I provided information on a survey undertaken in 2007 through a carefully constructed questionnaire involving paediatric SLT clinicians across the United Kingdom (Joffe & Pring, 2008). It sought to build a detailed picture of routine practices, experiences and opinions around SSD. In 2010, another national survey was conducted of working practices and clinical experiences of paediatric SLTs (Pring et al., 2012). In A34, I report the findings from both surveys.
The 2007 and 2010 respondents The 2007 respondents comprised a representative sample of 98 clinicians from the health, education and private sectors. The proportion of children with SSD ranged from 40% or more of their caseloads (44% of participants) to 70% or more (10% of participants). The respondents’ clinical experience extended from 1 to 3 years (35%), 4 to 10 years (26%) and over 10 years (39%). Only 7% specialised exclusively in SSD, whereas 42% identified it as one of several specialist areas.
Data from the 2010 study were obtained online via Survey Monkey in three sections, Section A focused on the therapists’ level and type of expertise, work settings and work practices; Section B included information on assessment, treatment and management and Section C canvassed SLT’s views on changes in healthcare and the benefits to children with speech, language and communication needs (see Pring et al., 2012 for further details of the second study). Approximately 7.5% of paediatric SLTs in the United Kingdom; n = 516) responded to the new survey. They appeared broadly representative of paediatric therapists and their workplaces were UK wide. Most respondents worked in the National Health Services (87.6%) with 7.1% in private practice. Years of clinical experience ranged from 0 to 2 years (17.3%); 3 to 5 years (20.3%); 6 to 10 years (19.9%) and over 10 years (42.5%). Respondents were asked to identify the age groups of children with whom they worked classified across five levels: infants (<3 years), pre-school (3–4 years), junior primary (5–7 years), senior primary (8–11 years) and secondary (11–18 years). Most worked with more than one age group, with an average number of age groups across SLTs being 3.33. One hundred and ten (21.7%) SLTs worked across all 5 age-bands, and only 35 (6.9%) worked in only one. The main work setting for most respondents was mainstream schools (67.4%) and community clinics (52.3%) with some working in special schools (25.4%) and specialist language units (23.5%). The average number of settings for SLTs was 2.34, with some seeing children in five or six different settings.
Generic versus specialist SLTs working in SSD The respondents were asked to indicate, using five broad categories, the time they spent on specific areas of clinical practice: none; 1–25%; 26–50%; 51–75% and 76–100%. Of the 516 respondents, 428 (82.9%) worked with children with SSD. This high percentage reflects the dominance of SSD in routine clinical practice of paediatric SLTs in the United Kingdom. Of the 428, only 9 (2.1%) reported working in this area for over 75% of their time. Thirty-nine (9.1%) worked with SSD between 51% and 75% of the time, 113 (26.4%) worked in this area between 26% and 50%, with the majority, 268 SLTs (62.6%) working between 0% and 25% of the time with this client group. It appears that an overwhelming majority of paediatric SLTs work with SSD in addition to a range of other difficulties within their expertise. Not all the SLTs working more than 50% of the time with children with SSD perceive themselves as specialists in SSD. Indeed, only 23 of the 48 SLTs (47.9%) working with this client group over 50% did so; whilst 110 of the 381 SLTs (28.8%) working with this client group for less than 50% of their time viewed themselves as specialists in this area. This indicates that most SLTs working with children with SSD are not specialists in the field, and that many affected children are seen by non-specialist SLTs. This is a similar finding across all types of paediatric speech and language disorders, except for paediatric dysphagia, where specialists see most clients (Pring et al., 2012). These data reflect the respondents’ comments. One-fifth of them (20.5%) said their caseload did not utilise their specialist skills. Critical that the structure of their service required them to be generalists, respondents expressed frustration at their inability to use or establish their specialist areas. They identified heavy caseloads, with insufficient time for reading, training and mentoring less experienced clinicians as a main reason why they could not develop their specialist areas. This worrying trend of SLTs being restricted by their managers (frequently non clinicians) in attending training and other CPD has been identified by the RCSLT. It is being addressed by the College through several initiatives, for example, the creation of RCSLT regional hubs to encourage greater collaboration across SLTs and higher education institutions (Gadhok, 2013), and the name change for specialist groups, from ‘Specific Interest Groups’ to ‘Clinical Excellence Networks’ to highlight the importance of training in achieving clinical excellence (Harulow, 2013).
A day in the life of a paediatric SLT In the 2010 survey we explored participants’ time management, asking them to quantify the time they spent on assessment, intervention (direct and indirect), on report writing, attending meetings and administration. As a whole group, 22.4% reported to be involved in direct intervention, with 27.5% involved in indirect intervention (14.8% training other professionals and 12.7% training parents). Conducting and analysing assessments took a further 13.2% of time with the remainder on some combination of administration, meetings and report writing. Thus, less than 25% of their time is devoted to direct intervention. Over 40% of SLTs (44.7%) felt their workload and distribution did not make the best use of their time. When asked what their ideal work distribution would be, the percentage of time increased for intervention to 64.5%, with 28.3% of time for direct intervention. Time allocated for all other activities, including assessment, were reduced (Pring et al., 2012). Twenty-five percent of SLTs working with SSD reported to undertake direct speech intervention more than 50% of their time with only 5.8% and 3.9% conducting indirect therapy with the training of other professionals and parents over 50% of their time, respectively.
Whilst the survey did not have a category for keeping current with the literature or undertaking research or research-related activities, there was an open category, ‘other’. No participant mentioned research or any research-related activity in this category.
Assessment In our first survey, the participants identified 21 assessments, between them, that they used most frequently to identify and assess SSD, with majority (85%) nominating the South Tyneside Assessment of Phonology: STAP (Armstrong & Ainley, 1988; 1992). A picture emerged of clinicians choosing this quick screening tool, supplemented by other non-standardised assessments, including personally designed assessments and informal observation. The picture remained similar in 2010 among the 221 therapists who worked mainly with children with SSD. Fifteen assessments were identified between all 221, with most identifying the STAP as their assessment of choice (27.6%), compared with the Diagnostic Evaluation of Articulation of Phonology (DEAP) (11.3%) (Dodd, Zhu, Crosbie, Holm & Ozanne, 2002), the CLEAR Phonology Screening Assessment (9.5%) (Keeling & Keeling, 2006) and the Nuffield Dyspraxia Program Assessment (8.5%) (in Williams & Stephens, 2004). Sixteen percent identified ‘informal assessment’ as their assessment of choice, with 9% identifying the Renfrew Action Picture Test (RAPT) (Renfrew, 2010). The top reasons for their choices were: test availability speed and ease of administration, scoring and analysis; and test familiarity. The specific reason for including the RAPT was to quickly gain an overview of language ability together with speech in context.
The popularity of the inexpensive, small, easily transportable STAP and CLEAR with their quick administration and scoring, plus informal observations is somewhat understandable. Regrettably, they are unlikely to provide sufficient detail to permit adequate description, diagnosis or optimal therapy planning. Moreover, there is a danger that incomplete or insufficient assessment protocols will seriously limit intervention practices (Bernhardt & Holdgrafer, 2001a, b). It is pleasing, therefore, that the DEAP was more prominent in the 2010 survey and second to STAP in popularity, albeit with much less frequency.
Alternative, detailed linguistic analyses such as psycholinguistic profiling (Stackhouse & Wells, 1997) and non-linear analysis (Bernhardt & Stemberger, 2000) enable more precise identification of the nature and levels of speech impairment (see Bernhardt & Ullrich, A37; Gardner, A27; Froud, A38). These analyses take more time than STAP-type measures, and perhaps more time than many clinicians might have. This is reflected in the second survey with only one therapist mentioning the psycholinguistic framework and none mentioning non-linear analysis. They also require specialist knowledge, sometimes necessitating additional training. The financial climate has, if anything worsened since the first survey and clinicians are increasingly restricted in the CPD/CEU events they can attend, exacerbating a situation in which the 2010 respondents identified heavy caseloads and insufficient time for reading as major barriers to developing specialisms. Additionally and anecdotally, UK SLTs fear implementing in-depth speech analyses, sometimes acknowledging their own lack of expertise, like one 2007 respondent who claimed she and some of her colleagues were ‘terrified’ by psycholinguistic models (Gardner, A27 provides reassurance!). The few references to psycholinguistic profiling in the 2010 survey suggest this fear and uncertainty persists.
The 2007 and 2010 respondents noted dissatisfaction with their limited assessment options, and were often unable to extend their choices due to financial restrictions. We found that some workplaces could afford just one copy of an assessment, obviating its routine use throughout a service. For example, the DEAP costs over £300, so most clinic budgets can only extend to purchasing one or two. Clinicians using screening measures rather than comprehensive phonological analysis mean they gain insufficient information for selecting the most appropriate intervention and treatment targets for an individual child.
Therapy, clinician confidence and evidence
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