Phonology Assessment in SLP Private Practice

I am continuing with a series of blogs about private practice speech-language pathology. Fortunately many new clinicians can join an established practice and won’t have to think about these things. More frequently however young SLPs are setting up their own practice right out of school or very early on, in their home during their maternity leave for example. The focus of this blog is an aspect of setting up your practice that I am not seeing much advice about in other blogs (maybe I missed blogs about this, please write with links if I have). There other excellent blogs on setting up a private practice, for example 5 Key Steps to Start a Speech Therapy Private Practice (speechbuddy.com). ASHA also has a site the links to many key resources on the topics including ethics issues and quality indicators for your practice: Private Practice in Speech-Language Pathology (asha.org). I recommend these sources, but I am going to fill in a small but critical gap and that is the necessity of having the appropriate assessment materials on hand before you begin. And because you must obtain proper copyright to the materials or buy them (do not borrow them from your other employer!), I will provide some costing information.  In the last blog I talked about the importance of expertise and specializing in those clients you are most qualified to serve. Therefore, I will focus on speech sound disorders in children aged approximately 3 through 8 years.

The need to have assessment materials should be obvious. The practice guidelines world-wide indicate that your treatment goals and plans must be based on the results of a comprehensive assessment. Often times I see SLPs trying to select goals and treatment methods without having the results of a comprehensive assessment to guide their choices. How does this happen? There are so many reasons, almost too many to count but a few of them are unique to the private practice environment. Clients may not want to pay for the time it takes to assess when they are so desperate for treatment and their insurance may cover only 6 sessions. And the SLP may not want to pay for assessment materials when they are so expensive and observation can be valuable. Free observation is not a substitute for systematic assessment and analysis of the data in any circumstance. In the next blog I will demonstrate all the ways that superficial observations can be misinterpreted or at least differently interpreted. Even if the data is a detailed speech sample, a transcription and phonological analysis will be required. So which assessment tools are minimally required? Francoise and I developed a rubric for this, shown as Figure 5-1 in our DPD text and Figure 3-2 in our IntroSSD text. I will show the types of assessments in the table below, including those that are mandatory and those that are optional* and suggest options for each with free and commercial sources indicated.

ConstructPossible TestSource
Contextual factorsCase historyDPD text Publications :: Plural Publishing
Articulation accuracyDEAP Articulation TestDiagnostic Evaluation of Articulation and Phonology (DEAP) (pearsonclinical.ca)
StimulabilityDEAP or informalInformal is fine
Oral-motor screenDEAP or other publishede.g., DPD has 3
Speech accuracy in continuous speechReference data for Percent Consonants Correct) Shriberg et al.Reproduced in DPD or see Austin & Shriberg (1997)
Hearing acuityHearing screeningFree apps: HearScreen — THE AUDIOLOGY PROJECT
Phonology*DEAP or hand scored from conversational sampleSee above or DPD
Word Inconsistency*DEAPSee above
IntelligibilityIntelligibility in Context ScaleOverview – Multilingual Children’s Speech (csu.edu.au)
Speech Perception*Speech-Production Perception Task or SAILSFree procedure in DPD or see http://www.dialSpeech.com
Phonological Awareness*Phonological Awareness Test (implicit)Free with norms in DPD
Nonword Repetition*Syllable Repetition TaskOverview – The Phonology Project – UW–Madison (wisc.edu)
Language screene.g., QUILS (3 to 5 yrs) or SPELT (4 to 9 yrs) Or story retell with SALTLanguage Screening Tools – QUILS (quilscreener.com)
SALT Home Page (saltsoftware.com)
Intelligence screen*Kaufman Brief Intelligence TestClinical Assessment Canada – English (pearsonclinical.ca)

This list of required test materials looks lengthy but the ultimate cost is quite moderate. Instructions and normative data for the case history, the oral-peripheral examination, articulation and phonological analysis for toddlers through school age children (with normative expectations), speech perception testing and an implicit awareness test are all tucked inside the DPD text which can be obtained for $150.00. Measures of intelligibility, a hearing screener, and the syllable repetition task are available free on the internet. You should have a standardized measure of articulation and/or phonology. I like the DEAP because it is comprehensive with good diagnostic properties; it costs about $600 with test forms. You can measure expressive language abilities informally although it is time consuming to do so. For younger children the QUILS receptive language screener is only $100. Generally standardized tests are in the $300 to $600 range unfortunately.

You might question the value of the optional tests, especially the K-BIT. However, I strongly recommend having the Kaufman Brief Intelligence Test because it includes a receptive vocabulary test as the verbal IQ screen and a nonverbal IQ screen and often you need a little bit of extra information to justify referring children to a psychologist. I have struggled to achieve progress with quite a few preschoolers in my practice who turned out to have very significant but undiscovered cognitive delays. The K-BIT is sold by Pearson for about $500. For children younger than four a play skills assessment can be a good substitute.

So, not worrying about exchange rates and rounding around the edges, you can count on spending $1500 on assessment materials in your first year. You should count on spending that much every year in order to update your editions and add tests in areas not covered by this stripped down list. After you add your provincial and federal association fees and your malpractice and liability insurance you are still not paying very much to start charging people for your services. The real costs come with actually conducting and then scoring the tests, and in phonology, analyzing the data. However, that is the competence that your clients are paying you for. More about that in the next post.

Expertise in SLP Private Practice

I have not been writing blog posts for some time. I miss it. I enjoyed spending cold weekends at my cabin, by the fire, researching a new topic, hunting down references, and putting my thoughts to paper. Even with typos and half-formed thoughts, those blogs felt like an accomplishment and so many people read them! To this day. But I gave it up because my position as school director took so much time (you will not believe what I do on Sundays now) and also I froze my right shoulder and it became painfully impossible to type for long periods, seven days a week. After three months of physiotherapy, started way too late, I can finally move my arm, and I have decided to write some blogs again. The physio is relevant because I have been thinking about private practice, both the excellent service the physio provides, my own practice given up 20 years ago, and all the young practitioners that I am talking to because they contact me for help. In the past only very experience SLPs started their own practices but now it is common for people right out of school to end up in private practice of one form or another. Since I don’t have time to research weighty topics, I will set down what will be essentially rants about the right and wrong way to do this because I am seeing some stuff that curls my hair frankly. When the mood hits me, a different aspect of setting up a practice, starting with the most important resource that you need to put into your practice: expertise. What is expertise? Why is it so important in private practice? How do you gain expertise in private practice?

What is expertise?

In Canada clinical training now reflects a competency-based approach. The Canadian framework adopts a “daisy model” in which numerous professional roles are arranged around the core “expert” role. The daisy organizes the different competencies that are required for entry-to-practice with the expectation that competencies will improve and deepen with further practice. The expert role is defined over many pages of specific competences but boils down to this: apply knowledge of development and disorders of communication together with assessment and intervention skills to clinical practice. Another definition of expertise that I really like is: “apply skills and knowledge of the discipline to make decisions with limited information in relevant contexts.”

Why is expertise so important in private practice?

Expertise is always essential but especially so in private practice: in sole-practice settings, the SLP is completely responsible for her own decisions. In larger public organizations there is an infrastructure to support decision making. In schools for example, who gets service and what kind and how much might be completely determined by regulation. The type of service provided might be a matter of tradition or culture, rightly or wrongly. Certainly, you will have colleagues that you can consult when you need help. Your employer will send you to conferences and provide professional development. You don’t have that support structure in private practice. Your client will expect you to justify your decisions directly and you will need to do that on the basis of expertise and that means knowledge. On average, your clients will be richer, more educated, and will consider themselves to be more discerning about their needs. For sure, they will have a choice about whether to accept or abandon your service. I have walked out on physiotherapists in the past because they told me to do what they always do; lacking a rationale, I had no faith in their practice. I am willing to pay a lot of money to the current practitioner because I can tell that he has a coherent theory of practice and that he is using deep knowledge to guide his treatment plan and solve problems. I am motivated to engage in an hour of painful exercises a day by visible evidence of progress and confidence in the therapist’s competence. Even children will find tangible evidence of learning and positive assurance from their SLP more motivating than stickers. You have a professional duty to demonstrate competence. This means a coherent theory of therapeutic change, deep knowledge of development and disorder(s), and a clear link between that knowledge and your practice.

How do you gain expertise in private practice?

Naïve models of expertise assume that it accumulates over time as you acquire “more” of something. Recall that the definition is essentially apply knowledge and skills to clinical practice. It has been assumed that teachers with more years of education will be more competent than those with less as a consequence of greater knowledge but this has not generally been supported by research. It has been assumed that psychologists with more years of practice will achieve better results than those with fewer as a consequence of better skills but research dispels that notion as well. Private SLPs like to acquire more skills through the accumulation of certificates attesting to their ability to apply new techniques or programs. However, the acquisition of more knowledge or skills or even practice does not add up to expertise unless the result is greater ability to solve problems. For this reason, practice with feedback is key. Feedback, that is your client’s response to therapy, provides invaluable information about the efficacy of your practice (feedback from mentors helps but feedback from your clients is more important and pertinent). SLPs do not always use client information as a clue to the efficacy of their practice. Often the client’s progress or lack of it is attributed to factors outside of the SLP’s control which is unfortunate. There is no opportunity for learning and no chance of deepening expertise if the client’s progress is not taken as important evidence of your own competence.

What if you observe that your client is not progressing? I often present data in my conference talks from a child who made literally no progress over a three year period. He was receiving lots of intervention from public therapists and the same private therapist over that time. But there seemed to be no recognition of his flat trajectory. It was astounding to see it in our research data. How is it possible? In fact, I have seen this happen quite a bit in my research. It seems that we have a tendency to practice on the basis of past experience while by-passing both knowledge and feedback, like this:

Client A: Symptom A: Apply TxA: Achieve success

Client B: Symptom A: Apply TxA: Achieve no success: Repeat

In this case, the treatment plan for Client B is built on the basis of experience (practice) with a previous client without integrating past knowledge or current feedback. The necessary knowledge relates symptoms to diagnoses, like this:

Client A: Symptom A+B: Diagnosis A: Apply TxA: Achieve success

Client B: Symptom A+C: Diagnosis B: Apply TxB: Achieve success

I am pretty sure that SLPs are failing to apply knowledge to problem solving quite often because when they ask for help, they do  not have all the information they need to form a diagnosis and when I refer to my book, the one I taught them with, they don’t have it! How can you apply knowledge to solve a problem if you don’t have your knowledge with you? And how can you solve a problem if you have not analyzed all the parameters of the problem? This brings me to the last point I want to make about expertise. Knowledge and applying it appropriately is an essential part of the picture. It is hard to know about everything (I have forgotten more about syntax than I ever new, its shameful really). So, private SLPs should specialize. Start with one thing you know a lot about and then make sure you know more about that every day. You can add another specialty area after awhile if you get really knowledgeable and well practiced with the first one. Do not pretend to be an expert in everything. If you advertise your services in everything your colleagues in the milieu will know that you are not a serious member of the private practice community and you will not be serving your clientele properly. If a person calls and asks you to provide a service you are not competent to provide, refer them to a person who is competent to provide it. If no-one is and you are their best shot, tell them you are not too sure about what to do and you will need to consult experts along the way. Never pretend to be an expert when you are not. It is unprofessional and embarrassing. Fortunately, it is not that hard to become an expert in most parts of SLP once having obtained your degree. Basically, read stuff, lots of stuff including basic science and practice guidelines. Be careful what you read because some stuff is not credible. Read real stuff by real experts. Apply what you read and pay attention to the results.