Preschoolers are being pulled out of classrooms to get speech therapy to work on “artic.” Even toddlers are getting articulation therapy in either clinics or one-on-one sessions at home or in child care. This article debunks these atheoretical practices and proposes better help for children and their caregivers.
Articulation is Developmental
Children cannot fully articulate spoken English until 7 or 8 years old. By age 4, children can be understood most of the time, even with their articulation errors. Various sources report what research tells us about typical ages for the development of different sounds. Shriberg (1993) classified the developmental sequence into the Early 8, Middle 8, and Late 8 (EML):
In early intervention for children under the age of three, one would like to think articulation therapy was not occurring for the Middle and Late 8s, but, unfortunately, that’s not the case. Furthermore, the range of typical ages for pronouncing sounds is large, so why rush to therapy?
The problems with articulation therapy, as commonly found in EI/ECSE programs are
- The need for the therapy is often faulty: The child is not delayed in speech sound development;
- Methods used in articulation therapy were developed for older children;
- The whole premise of one or two articulation sessions a week for a child under the age of 6 denies how children learn;
- The service delivery method for articulation therapy often involves a quiet space with no distractions, which is not a space the child has to live in, so the context is irrelevant;
- Young children, especially if they also have a developmental delay, don’t generalize well (e.g., from a distraction-free therapy environment to real settings); and
- It misleads parents into how children learn to speak intelligibly: They think it’s from short weekly or twice-weekly sessions, instead of through their own efforts.
Later, in the section on arrows in a quiver, I discuss the importance of SLPs; knowing about in vivo, naturalistic methods for (a) coaching caregivers to (b) address speech sound disorders.
Articulation therapy is one of the most iatrogenic services in EI/ECSE. As Ivan Illich noted in 1974, social iatrogenisis can occur with the medicalization (or speech-language pathologization) of life, where professionals have a vested interest in sponsoring disability by creating unrealistic articulation demands that require more therapy or by providing therapy for non-problems that are part of child development, such as undeveloped articulation. As cynical as it might sound, the supposed need for articulation therapy serves the interest of the SLP profession, but the six problems outlined above emphasize the dangers of allowing this iatrogenesis to go unchallenged.
Confusion Between Articulation and Phonological Delays
SLPs know this difference but, presumably, they sometimes forget it, perhaps because they realize lay people might not understand phonology but they do understand articulation. Articulation, simply, is the motor act of pronouncing the sounds correctly. Phonology is how sounds are organized in a language. Children with phonological delays are sometimes described as knowing what they want to say but being unable to get the words out correctly. One can imagine how different the intervention strategies should be for these two scenarios carrying the same service (i.e., SLP). Phonological delays are much more likely to occur in preschoolers than are articulation delays, yet we hear mostly about “artic.” This makes me wonder if practitioners are aware of the difference. Phonological awareness by the child and intervention by caregivers can happen throughout the day, in regular routines. Articulation, as commonly practiced, is often done just by an SLP in a specialized setting. I will argue that, even if the child truly has an articulation delay/disorder, evidence-based interventions can be carried out in ordinary places by ordinary people.
Even if the child truly has an articulation delay/disorder, evidence-based interventions can be carried out in ordinary places by ordinary people.
One SLP blogger, Laura Mize, makes the point that apraxia therapy can be done almost entirely in the context of eliciting communicative behavior from the child, in fun activities. This does not require taking the child to a segregated setting.
Context-Based Articulation Therapy
The past president of the Mississippi Speech-Language-Hearing Association, Dr. Rachel Powell (2015), has discussed context-based articulation therapy to help SLPs be accountable for student success within the curriculum. This accountability became necessary with the implementation of the Common Core State Standards in Mississippi. She also cites research documenting the association between reading and SSD. She reported on two students whose SSDs were addressed by the SLP during reading time—a regular part of the curriculum. The SLP had used context-based reading to target speech sound errors and targeted speech production with grade-level text she selected. Here was the intervention: “As the student read, any words containing the target sound were
–Acknowledged for correct sound production
–Corrected by the child following feedback from the SLP or self-corrected
–The SLP guided the child to a more correct production of the word.” (Slide 20)
This is not rocket science. I would suggest that most any teacher or parent could do these three interventions. The SLP would have been needed to diagnose the errors, possibly, and probably to recommend which sounds to target. But if she would engage in role release (Bruder, 1993) with the teacher—and parent, for that matter—teaching them to conduct these three steps in reading or even in conversation, the children would receive many more interventions than just during SLP sessions. The idea of context-based articulation therapy was a good one. It just didn’t go as far as it could have.
Speech Therapy Dosage Is Predicated on Incorrect Assumptions
The dosage of speech therapy is usually predicated on an assumption that (a) children are learning speech sounds during therapy and (b) one or two sessions a week make a difference. The problem is that we conflate intervention with service. If we consider intervention to be what the child receives, we realize that the greatest influence on children’s speech and language comes from whoever spends the most time with the child. If we consider service to be what the family receives, say, from an SLP, we realize that there is little correspondence between this service and intervention. Furthermore, service needs to consist of building caregivers’ capacity, rather than working directly with the child.
A little-known fact is that the research on service delivery models in SLP is not convincing about the usual ways therapy is provided. In a review of 14 randomized control trials of speech-language interventions, improvement was seen in a number of outcomes, including articulation, phonology, and expressive and receptive language (Nelson, Nygren, Walker, & Panoscha, 2006). In other functional outcomes, such as socialization and self-esteem, which were measured in four of the studies, the results were mixed. None of the studies included long-term effects. The authors concluded that the findings were limited and that generalization effects were unknown. Therefore, the RCT literature reveals underwhelming support for speech and language interventions.
All the Intervention Occurs Between Visits
A meta-analysis of efficacy studies of treatment for children with developmental speech and language delay or disorder was conducted with 13 studies meeting inclusion criteria. The analysis showed that “speech and language therapy might be effective for children with phonological or expressive vocabulary difficulties” (p. 924; emphasis mine) (Law, Garrett, & Nye, 2004). For children with expressive syntax difficulties, the evidence for effectiveness was mixed, and, for children with receptive-language difficulties, the evidence was little. Most important, “No significant differences were found between interventions administered by trained parents and those administered by clinicians” (p. 924).
The well-known Hanen Early Language Program refers to children with CAS as having suspected motor speech disorder. Even with this disorder, the Hanen approach is to work with parents to provide a supportive, encouraging communicative environment. When children have isolated expressive language delay, they are best served through an service delivery approach that supports parents as responsive communication partners.
ASHA (1996) advocates for inclusive service delivery, meaning in the context where children naturally are and in collaboration with the adults in those settings. Their position statement includes a caveat that their interpretation of inclusive practices can include direct intervention programming but it can also include “classroom-based, community-based, and consultative intervention programming.” The Association’s statement shows fear of “absolute terms,” meaning they want all options to remain open, which gives those of us who understand how young children learn the freedom to lean on classroom-based, community-based, and consultative intervention programming with vigor.
Evidence for Indirect Therapy
Indirect therapy is the same as what I call consultative therapy, where the SLP works with the adults in the child’s life (e.g., teachers) so they can apply speech and language interventions in the SLP’s absence. In a Scottish study of 163 children with low language scores and normal IQ, no differences were found among direct individual, direct group, indirect individual, and indirect group (Boyle, McCartney, Forbes, & O Hare, 2007). All these treatment groups received 20 hours of therapy across 15 weeks. In a study of 2- and 3-year-olds with 30 or fewer words, fortnightly group parent training sessions produced statistically significant improvement in language skills (Gibbard, 1994). No statistically significant differences were found between the group of children receiving direct individual speech therapy and those receiving indirect “parental training” in speech and language. This latter group made more gains than did children receiving indirect parental group training in general cognition (i.e., nonspecific therapy). Other studies have documented the benefits of indirect versus direct SLP for young children. Old ones were reported in a book called Rethinking Pull-Out Services in Early Intervention.
How Children Learn
Brain science has helped us understand how learning occurs, even if it hasn’t given us any strategies behavioral research hadn’t already provided. Neuroplasticity explains how the brain’s ability to change its structures because of internal (i.e., genetic) and external (i.e., experiential) factors lead to learning (Hodge). Relevant areas of the brain cortex have improved synaptic connectivity brought about through experiences induced by training. To best capitalize on brain plasticity, we should (a) use child attention (e.g., to speech input), (b) give the child opportunities to use the area of the brain where we want to see increased plasticity (e.g., speaking, not nonspeech exercises, such as oral-motor exercises), and (c) have the child learn skills in the contexts where the skills are needed (e.g., everyday routines), because repetitive exercises removed from context have had disappointing results.
As the key component of these children’s environments, parents need to provide abundant social interactions within the child’s daily routines, and within each, create multiple “mediated” opportunities (“multiple doses”) to obtain the child’s attention and “tempt” the child to produce “speech like” vocalizations, in fun and playful learning activities….
It follows that a key role for speech-language pathologists is to guide and support parents in developing the necessary techniques, skills and confidence to foster the child’s communication development and to maximize the child “speech learning” ecology through education, and active modeling and coaching. (Hodge)
Apraxia is Not an Excuse for Atheoretical Service Delivery
The American Speech Hearing and Language Association’s (ASHA) Technical Report on CAS “recommends treatment for CAS be frequent, intensive, individualized, and naturalistic” (American Speech-Language-Hearing Association, 2007b). Although some commonalities in treatments exist, such as much practice, few treatment targets, homework, and feedback, many differences also exist (Maas, Gildersleeve-Neumann, Jakielski, & Stoeckel, 2014). The research has not unpackaged which components are actually the most effective. Therefore, the claim that a child has apraxia is not a reason for using non-evidence-based practices with him or her.
Confusion Between Apraxia and Phonology
Whereas apraxia therapy focuses on movement, therapy for phonological disorder focuses on sound sequences. According to Ruth Stoeke, a researcher on childhood apraxia of speech (CAS), the most empirical evidence is for integral stimulation or dynamic temporal and tactile cuing (DTTC), involving the shaping of movement gestures for speech production, using a systematic hierarchy of cues (Smith, 2014). But studies have no involved many children, and it can best be considered a promising practice. DTTC, however, is hard to fit into everyday routines, because it includes massed versus distributed practice (e.g., 100-200 repetitions of a skill during a traditional session). Stoeke said she never has children doing “exercises,” but will have them doing “speech work.” In other words, she has the child learning the movements by using speech, rather than practicing nonspeech tasks such as chewing or blowing.
The problem is that the research on CAS is of insufficient quality to justify using atheoretical practices, such as pulling a child out of the classroom or using direct hands-on treatment instead of a caregiver-mediated intervention. First, the diagnostic criteria for childhood apraxia of speech (CAS) are controversial (Morgan & Vogel, 2008). In 2007, The American Speech Hearing and Language Association (ASHA) found consensus that it consists of three core impairments: (1) inconsistent error production on both consonants and vowels across repeated productions of syllables or words, (2) lengthened and impaired coarticulatory transitions between sounds and syllables, and (3) inappropriate prosody. Second, in the Morgan and Vogel Cochrane review, 31 abstracts appeared to meet inclusion criteria, but they were all eventually excluded for not meeting the research design criterion. Therefore, no review was possible. In other words, a critical lack of well controlled treatment studies obviates any claim that certain practices have to be done because a child has CAS.
An Effective SLP Has Many Arrows in Her Quiver
The SLP who believes that all children with a certain disorder should receive treatment in a particular way are limiting their effectiveness. Of course, it could be argued that I believe that all children should receive their speech therapy through collaborative consultation with caregivers, which is true, but the actual interventions devised by the SLP-caregiver team should be highly individualized to the child, the caregiver, and the routine.
Miron (2012) has written about the negative attitude that professionals used to have about parents—that they were in denial and did not make appropriate adaptations for their children with disabilities. We now know much more about the adaptations that many families do make (Mas, Giné, & McWilliam, 2016). In Miron’s study, 11 parents of children with CAS were interviewed in depth. The study found that parents made a transition from helplessness to adaptation because of a positive critical encounter with an individual professional plus a single significant negative experience (i.e., [sic] misdiagnosis by the school) or a culmination of minor negative experiences. This study highlighted the importance of support from professionals to families (McWilliam, Tocci, & Harbin, 1998).
As mentioned earlier, SLPs cannot continue to sit down and work with a toddler or a preschooler on articulation. In those quivers, they need to have strategies they can teach to caregivers—strategies to teach the child to produce sounds correctly and intelligibly. If the child is old enough!
Countering the Critics
“Only SLPs Can Address This Issue”
Not surprisingly, for children with apraxia ASHA has stated “Although home practice is critical for optimal progress, it cannot take the place of individual treatment provided by a speech-language pathologist who has expertise in motor speech skill facilitation” (p. 30) (American Speech-Language-Hearing Association, 2007a). It goes on to endorse intensive therapy, such as five sessions a week. It recognizes that young children might not tolerate more than 30 minutes a session. Unless SLPs plan on adopting these children, they need to rethink their partnerships with caregivers. Of course they advocate for intensive services. What else could they do if they believe that only SLPs can help these children. They need to concentrate on (a) interventions caregivers actually can carry out, in collaboration with SLPs, and (b) teaching SLPs how to be collaborative consultants to caregivers. Changing beliefs is hard—harder even than changing stubborn behavior. So programs need to force therapists to acknowledge how children learn by making them collaborate with caregivers. Some SLPs will leave, but most will stay, and those who stay will change their beliefs about caregiver competence. Just as important, the stayers will recognize that it’s their responsibility to help caregivers gain competence and therefore confidence. They need to stop assuming incompetence in caregivers, as ASHA seems to, and ensure children actually get intensive interventions, which can come only from their caregivers.
ASHA has produced a handout for parents, called “Articulation and Speech Sound Development,” with sections on “Ways to help your child pronounce sounds and words correctly” and “How can I help a child pronounce words correctly?” (http://www.sparta.org/UserFiles/Servers/Server_956967/Image/articulation.pdf). This is the same professional organization that elsewhere has said all the intervention must come from a licensed SLP. But if they acknowledge that, in fact, parents can help their children pronounce sounds and words correctly, the argument for direct, hands-on articulation therapy are suspect. I’m sure they meant that families can supplement what therapists do. Later, I will argue that doesn’t go far enough, because valuable therapy time will be wasted with the SLP communicating with the child instead of the adult. The only time therapists should spend time with children during therapy sessions should be when demonstrating strategies to the adult, if the adult wants or needs the demonstration.
“What We’re Trained to Do”
Traditionally, SLPs were trained to work directly with children for two reasons: First, they had to demonstrate competence in the practice. Second, the training programs used to prepare practitioners to work in rehabilitation centers, schools, and other places, where direct, hands-on work might be appropriate. And then along came the little kids, those who could not remember from one session to another, let alone 5 minutes after the session. How on earth were we preparing SLPs to work with infants, toddlers, and preschoolers? The two big flaws in the training many SLPs have had are (a) lack of training in the pedagogy of very young children (i.e., how children learn) and (b) lack of training in collaboration and consultation. So the argument that SLPs alone should call the shots about service delivery doesn’t hold up. Fortunately for all of us, a number of SLPs get it, and one can only hope their influence is great and wide.
“Apraxia Is a Special Case”
A well-known method for practitioners to seek exception from trends in service delivery they don’t like is for them to point to supposedly special cases. In SLP, apraxia has become that scapegoat. In OT, it’s “sensory kids.” In special education, it’s kids “on the spectrum.” As though these situations obviated principles of child development, learning, and teaching. I have dealt with the apraxia argument in an earlier section.
Administrators, forward-thinking SLPs, other team members, and parents will encounter critics who want to work directly with young children in isolated settings. They will use these arguments and others. We should listen to them and weigh their arguments against the evidence, the principles of our work (which should be rooted in research and theory), and the moral imperative to give children the most learning opportunities possible, while empowering their caregivers. When we do that, we will usually find that SLPs aren’t the only people who can address the issue, they are not necessarily trained in the requisite skills, and apraxia is not a reason for an exception.
Most studies show that an indirect approach is at least as effective as direct, hands-on therapy and, of course, it has the advantage of being theoretically sound and the right thing to do. We need to be careful not to fall into the “Show me the money (research)!” trap. It’s more essential that the theoretically unsound people show the evidence for what they want to do.
Routines-Based Model for Increasing Intervention to Children With SSD
A model exists for giving children with SSD intensive interventions in a way that might actually help them: The Routines-Based Model of Early Intervention for Children 0-5 and Their Families (McWilliam, 2010). In this model,
- The informal supports of the family are identified and then used as appropriate, to meet family needs;
- Children’s engagement, independence, and social relationships (including communication) are assessed through the Routines-Based Interview;
- Families identify 10-12 goals for their child’s functioning and their own family needs;
- Child learning goals are written to emphasize the child’s participation in his or her routines;
- Family goals are on every plan, including preschoolers’;
- A primary service provider (PSP) is identified to be the family’s “key worker”;
- Home visits are done with “family consultation,” in which parents and the PSP jointly develop strategies to meet child and family goals;
- Other team members, from other disciplines, serve the child through joint home visits with the PSP;
- Visits to children in child care are done with collaborative consultation, with the teachers and the PSP jointly developing strategies;
- Professionals’ training and performance are carefully monitored with implementation fidelity checklists;
- Child progress is measured with functional items organized by routines and by goal attainment scaling; and
- Family outcomes are measured with a measure of family quality of life and goal attainment scaling.
In some locations around the world, including the U.S., a PSP isn’t used or natural environments aren’t used. We have developed strategies to accommodate both of these imperfect conditions.
In an article about how this model supports speech and language, I have discussed the tenets of the model; how it works; how children learn and how services work; the speech and language needs of young children with disabilities; new roles for SLPs in an era of functional, family-centered early intervention, and the future of speech-language therapy in Spanish early intervention (McWilliam, in press). It applies to early intervention in other countries too.
SLPs, with their expertise, are vital, valuable resources to the early intervention (0-5) field. They have knowledge we need and a passion for helping children communicate and have social relationships. Their significance is enhanced when they acknowledge that articulation is developmental, that the dosage of intervention by caregivers is more important than the dosage of service by SLPs, that all the intervention occurs between visits, that children learn throughout the day (not in one or two sessions a week), that apraxia is not an excuse for atheoretical service delivery, that the effective SLP has many arrows in her quiver, and that a model does exist for providing services in an evidence-based, theoretically sound, and moral manner. I obviously recommend adopting the Routines-Based Model—I developed it!—but that’s because, as R. Buckminster Fuller said, “If you want to teach people a new way of thinking, don’t bother trying to teach them. Instead, give them a tool, the use of which will lead to new ways of thinking.”
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