Does speech therapy work?

I am writing a blog post, exceptionally, to respond specifically to a poster on @speech_woman’s list-serve who wrote to say that she is having a “career choice crisis” after 10 years of service. The poster is unsure whether she is making a difference because it is so hard to tell if each individual patient is improving due to her efforts or due to other events outside of her control (maturation, family and school inputs etc.). First I acknowledge this as a legitimate concern because in fact it is difficult for the speech-language pathologist to estimate in each case how much of an individual patient’s improvement can be attributed to the SLPs efforts specifically. Furthermore, I know that this particular crisis of faith is common among SLPs today. This summer I attended an excellent workshop on outcome measurement sponsored by Nancy Stonell-Thomas to launch the FOCUS (an excellent new functional outcome measure). One of the speakers (I’m sorry, I forget who it was) presented some outcome data collected at her rehabilitation centre. The SLPs were required to rate each patient’s progress toward their speech and language goals using goal attainment scaling and then use a check list to indicate the variables that, in the opinion of the SLP, accounted for the child’s successful or unsuccessful achievement of their goals. The fascinating result of this exercise was that the pie charts describing these explanatory variables were identical for both achievement of goals and failure to achieve goals: in both events, more than two-thirds of the pie-charts were associated with child and family factors as explanations for the child’s achievement or non-achievement of the goal. Most of the remaining factors were institutional, leaving the tiniest sliver associated with the SLP. In other words, SLPs did not believe that they had appreciable impact on the child’s rate of progress. It was the saddest conference presentation I have seen in 30 years. So there may be a lot of SLPs having a “career choice crisis” and it is not clear to me how these individuals get up in the morning and go to work. I think that a lot of the reason for this is that governments and employers have constrained the professional choices of the SLP so much that it may be possible that the SLPs in many institutions are not having a much of an impact which is sadder yet. Consider for example the Glowgoska et al. (2000) trial in which it was found that a community speech therapy service was no better than ‘watchful waiting’ – not a surprising result given that the service was rationed to six hours of contact per family over an entire year in the form of brief parent consultation sessions.

Notwithstanding the possibility that some SLPs are working in settings where the institutional constraints are so tight that the services may indeed be of little value, I want to demonstrate that SLP services, at least in the area of phonology/articulation, are very powerful. I will start in this post and continue with two more to be posted later this month. It pains me that that the poster to the list-service mentions 9 years of university education but seems unsure about the efficacy of speech therapy. It does not surprise me however because there are many text books that describe speech therapy procedures without saying a word about the research evidence that supports (or fails to support) to use of those procedures. Many people do not know for example that many quite good randomized control trials were conducted in the fifties and sixties and a whole host of well controlled single subject studies were published during the same period, laying down the empirical basis for our profession. It is important to have confidence in the efficacy of the treatment procedures that we employ in our clinical practice and ultimately, that confidence can only come from the published research literature in combination with the changes that we see in our patients from day to day. There are many ways to access summaries of this data. The Cochrane collaboration is the most well-known, and their meta-analysis of speech and language therapy (in a pediatric context) concludes that therapies for phonology and vocabulary are effective:

Law, J., Garrett, Z., & Nye, C. (2009). Speech and language therapy interventions for children with primary speech and language delay or disorder (Cochrane Review).  John Wiley & Sons, Ltd.

You can also follow @HealthEvidence and @speechBITE on twitter to receive news about the latest treatment efficacy studies. The SpeechBITE website has summaries of research efficacy studies in speech and language pathology.

When Françoise and I wrote Developmental Phonological Disorders: Foundations of Clinical Practice, we made a deliberate effort to support evidence based practice by (1) providing a literature review of the research evidence to support all the treatment procedures that we teach in the book; (2) with few exceptions, refusing to even discuss treatment procedures for which we could not find good quality supporting research evidence; and (3) providing information on how to measure treatment outcomes for each individual patient using both target specific and generalization probes.  We all know that evidence based practice involves integrating the best research evidence with your own clinical experience and the needs of the patient. The thing is – clinical experience should be objective just like research evidence – not just vague impressions about patient satisfaction – you really do need to measure the change in your patients at multiple levels. If you look at my previous post on CAS this is evident as the “session end” probes suggest that the children are making great gains each day but the “next day” probes indicate that in one of the treatment conditions the child is not retaining those apparent gains. When treatment is rationed to brief periods or infrequent contacts with patients, your impressions of change may not provide a true picture and therefore objective outcome measures become even more important.

So the short answer is, the research evidence absolutely shows that speech therapy works. Is it working with your patients? Only you can answer that by objectively measuring retention and transfer of what you are teaching. If you are using treatment procedures that have been validated by good quality research and the child is achieving your goals, you can conclude that you have made a difference in the life of that child.

In those environments where it seems that we are maybe not making a difference, speech-language pathologists need to take back our own profession. In Québec (where I am) the professional order spends all its energy fighting other professional orders. This is madness. The real battle is for the professional autonomy of the speech-language pathologist. We need to have the freedom to make decisions in the best interest of our patients. This is the fight that is worth fighting.

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13 Comments

  1. I think part of it is being realistic about who is appropriate for service and who is not ready or reached their current level of progress. Motivation, attention, age development of sounds, mouth shape etc all have a huge impact. If we are honest about who is appropriate for treatment and who is not, treatment will be more rewarding.

    Reply
    • I am not sure that I can go along with the idea that there are some patients who are inappropriate for service. If the child or adult is not functioning in society at a level that meets the expectations of the patient, the patient’s family and society at large, in our wealthy societies, I think that that individual can reasonably expect help to improve his or her functioning. You could decide that some other service provider is better suited to meet that patient’s needs, that is acceptable to me. But I have always had a problem with the idea that we just wait for the patient to meet some level of readiness for service. I have quite often been asked to consult on cases where the SLP was asking for support to put a client on “treatment rest” due to lack of progress. In every case I found that a change to more apprpropriate treatment goals or procedures made a world of difference. That being said I agree with you that realistic expectations on the part of the patient and the SLP are essential – functional goals selected in accordance with the ICF framework are essential and you are probably correct that this approach would increase SLP satisfaction. Susan

      Reply
  2. Nic Parker

     /  March 31, 2013

    I too read the list serve post you refer to and have not yet responded as I didn’t know how to. As a practicing speech and language therapist I feel I do make an impact on individual’s lives and that the gains made are as a direct response to the therapy provided but I didn’t have the research to back up my position. Thank you for providing those. I think we have all felt ineffectual at times. When I look back over my career it has always been as a result of the type of provision I was required to provide (I.e. not enough therapy due to lack of funding and caseloads too large for one therapist to manage) and not the actual therapy. Thanks again for reinforcing that speech therapy does work! I love being a speechie and would be devastated to find out that what I do every day does not make a difference. I look forward to reading your next installments.

    Reply
  3. Stephanie Morgan

     /  March 31, 2013

    I have no issue with the available research evidence to support various artic/phon based therapies. There are many decent studies out there. What I would like to know and I think the list serve person touched on this too, with regards to speech intervention, how much better is therapy opposed to maturation? Is there any specific evidence around that? This is what I query time and time again.

    Reply
    • Hello Stephanie, In order to determine if the therapy is better than maturation you have to have a randomized controlled trial. The Law et al. meta-analysis included only RCTs so when they concluded that treatments for phonology and vocabulary were effective, the implication is that these interventions lead to more improvement than you get from maturation alone. I will present some data relevant to this question in another post. Part of your question may have to do with the fact that most studies are rather short term and therefore a policy maker could argue that speech therapy causes faster progress over lets say 6 months than maturation alone but if you wait 7 years kids who get therapy will be the same as kids who don’t (I don’t believe that this is true but for argument’s sake, let’s consider the possibility). In this case you have to consider the social and academic costs of slower achievement of milestones throughout this 7 year period. I discuss these issues in greater depth in my book. Thank you for your comment. Susan

      Reply
  4. Absolutely agree with your comments and as an SLP also trained in Applied Behaviour Analysis it is imperative that we evaluate our client’s progress in a more quantitative manner so that we can more confidently and accurately discuss what works (and does not work) in what we are doing as SLPs. If single case studies are well constructed then (with sufficient numbers and replications from different SLPs/labs etc.) this can also lead to increasing evidence for the various treatments that we implement as SLPs. What I’ve seen when working with other SLPs is that they have not defined the treatment goal(s) in measurable ways (i.e., operationalize the treatment goal) and, as well, will target too many goals at once thereby lessening the intensity in any one target so that progress would be doubtful at best. Other fields (e.g., ABA) are also conducting studies to shape/change speech, language, social, and communication skills (which is within their scope of practice as well) and we should also be looking at the evidence from those fields and increasing our collaboration with them in order to serve our clients better.

    Reply
    • Thank you for your comment Tracie, I agree that it is important to not set too many goals. I am going to address goal setting further in my third blog post (to come) in this series. Susan

      Reply
  5. Kate

     /  June 24, 2013

    Susan love your blog. I scrolled down and saw this. I don’t disagree with anything you’ve said but I do want to clarify. I was the presenter at Focus and I don’t believe I was saying that the SLPs collecting the data believed that their intervention didn’t work or was not a significant facilitator of client achievement. In the short presentation there was no time to really clarify. I believe that the Focus will be an important addition to our client and program outcome management system, since it is a valid reliable tool to demonstrate the effectiveness of Slp services. I agree the pie charts did not tell the whole picture though they did capture some of the secondary reasons that explain why some children achieved outcomes and others didn’t. For example did the child regularly attend therapy sessions or not? Were the parents engaged in sessions or not? Did caregivers follow through? Was the behavioural team using a similar approach to communication intervention etc etc. Through this lens it maybe is not too surprising that both charts were similar. 

    When I look back over my career the clients and families I work with today are very different from when I graduated 40 years ago. I see a growing number of ongoing challenges for our profession.
    In BC, like many other provinces, we work with an ever increasing number of children of new immigrants and refugees from a wide variety of cultural and linguistic backgrounds with often very different belief systems. Families who have no English (or French) skills and yet who require services for their children. Assessment and intervention via interpreters is less effective than being able to communicate directly with child and family members and much more expensive to the system. With current graduation rates in our professions this will not resolve soon. 
    We work in a very complex service delivery system particularly with children with ASD and the increased percentage of children families with mental health issues, working parents etc etc.
    These are some of the issues that front line clinicians will continue to ponder re whether our intervention works.

    Reply
    • Thank you so much for writing, it has really been bothering me that I couldn’t remember who presented the charts but I have a very clear memory of them and they made a strong impression on me. I would be be very pleased if you would e-mail me. perhaps you would like to write a guest post and show the charts? Please write even if you don’t want to write a guest post. The difficulty of providing an appropriate service in this complex health care environment certainly plays a role in the SLP’s attribution of outcome to a host of external factors. I love the FOCUS too. Susan

      Reply
  6. Kate

     /  June 24, 2013

    I’m happy to put something together to send it to you.

    Reply
    • That’s terrific Kate, send it to my McGill email address, I look forward to hearing from you.

      Reply
  7. With all careers most people want a change because they do not see any progress. Its a sight of failure. Speech therapy is an occupation that revolves solely around the progress- has the child/adults speech improved since seeing you.
    The person who needs the therapy needs to continue outside of the therapy room to make sure there is improvement happening. The SLP needs to make sure they look at every aspect of that persons life to understand what could be affecting growth or decline.
    There are just so many factors that need to be considered. Persistent is the key.

    This is a great article. Thank you.

    Reply

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