Who to refer for speech therapy?

Morgan et al. have recently published a very important paper: Who to refer for speech therapy at 4 years of age versus who to “watch and wait”? This longitudinal study reports speech outcomes at age 7 years for children who received GFTA and DEAP assessments at age 4. The children were recruited from an Australian community cohort study (the Early Language in Victoria study) that recruited almost 2000 infants between 7 and 10 months of age for long-term follow-up.

The data reported in Morgan et al. is interesting by itself, as follows:

  1. Eleven percent of 1496 children tested at age 4 had speech errors qualifying the child for repeat assessment at age 7 years (the 11% finding interested me because we settled on 11% as the best estimate for prevalence of developmental phonological disorders at school entry in the review that we reported in DPD).
  2. At age 7 years, approximately 40% of the children who had speech errors at age 4 still had speech errors.
  3. Children at age 4 who had speech delay (typical speech errors; 60% of the sample) were most likely to show resolution of the speech problem. Specifically 70% of these children were classed as “resolved” and 30% as “persistent” at age 7 years.
  4. Children at age 4 who had a speech disorder (atypical speech errors; 40% of the sample) were less likely to show resolution of the speech problem. Specifically, 40% of these children were classed as resolved and 60% as persistent.
  5. No other variables in the study predicted speech outcome but neither did these variables predict “delay” versus “disorder” group membership (sex, SES, family history, language skills, nonverbal IQ).
  6. Apparently, reliable data on receipt of SLP services and outcomes was not available but there was some suggestion that children with “speech delay” who received therapy were more likely to resolve than children with “speech disorder” who received therapy.

Therefore, in this paper that is published in a journal for pediatricians the conclusion was “our data call into question whether the “watch and wait” approach should be universally applied to all preschool children. Rather these data suggest an efficient model may guide children with disorder at age 4 years to be fast-tracked for speech therapy…”.

The data provided in this paper are exceptionally important for SLPs and the development of service delivery guidelines but I am a little uncomfortable with the conclusions that were drawn. The first assumption I suppose is that doctors are not referring any 4 year olds so if we could get them to refer some that would help. The second assumption seems to be that the reason we refer 4 year olds with speech errors to speech therapy is to eliminate the speech errors. This is only partially true. More importantly, we have the goal of preventing the sequels that are known to be associated with delayed/disordered speech at school entry. These are mostly in the area of literacy but also in the psychosocial domains. It is clear that children who show early speech delays are at-risk for persistent literacy difficulties regardless of whether the speech problem resolves before at age 7. The important age cut-off is resolution of the speech problem before school entry. The risk for literacy difficulties is predicted by direct measures of phonological processing and not by an examination of speech error types. Certain speech error types are associated with phonological processing difficulties and a heightened risk for literacy problems but they are poor predictors of this risk. I will come back to this point with some case histories below.

The second problem that I have with the conclusions is that they are delivered to pediatricians who are in no way qualified to differentiate typical from atypical speech errors. In fact, SLPs themselves find this hard enough to do reliably. The difference between speech delay and speech disorder is both qualitative and quantitative– in other words the dividing line between delay and disorder is a very large grey area. Family doctors should not attempt to make this differentiation. In the paper, Morgan et al. do point out that the real issue is intelligibility. When the child is unintelligible past the age of 3 or 4, the physician should refer to a SLP who should determine the best course of action. In our review of the literature for SAC, Susan Raffat and I proposed wait times recommendations for children who are “ producing so many speech sound errors that speech intelligibility falls below expectations given the speaker’s age and experience with the language being spoken.” All children in the 4 to 6 year age group were considered by us to be high priority for a rapid assessment by an SLP. Any child with speech intelligibility problems who is expected to start school in the year of referral and/or presenting with phonological processing difficulties would be considered a high priority for immediate intervention.

Now to some case studies that I draw directly from our DPD text (Rvachew and Brosseau-Lapré), showing only portions here to make a point about speech delay, speech disorder and literacy outcomes. The first example is a clear case of speech disorder (data shown from age 7;4 assessment, right).

Complete information is provided in DPD, showing that two years earlier this child also presented with a severe speech disorder and severely delayed phonolCase Study DPD 8-4.JPGogical processing skills. His error types were atypical and inconsistent throughout the longitudinal follow-up period, despite much speech therapy targeting motor aspects of his speech. At age 7 his nonword reading skills were slightly below normal limits and 14 points below his receptive vocabulary scores. We can predict that he will struggle with the acquisition of reading and spelling in addition to continuing to have highly unintelligible speech for some time. Interestingly, his mother reported that his speech accuracy finally started to improve after a systematic phonics program was instituted to help him with his reading in second grade. The outcomes reported at age 7 will not surprise anyone.

The interesting findings for me were associated with the children with milder speech delay. The second child shown here (age 6;9 assessment, left) had a mild speech delay at age 4 but a severe delay in phonological processing skills that was, fortunately for him, treated appropriately by the SLP program in the local children’s hospital. At age 7 his speech delay is more-or-less resolved. His nonword reading skills are borderline normal but there is a 28 point gap between his nonword reading score and his receptive vocabulary scoreCase Study DPD 8-1. I think that this child is essentially dyslexic. He is coping well because he is exceptionally bright with excellent inputs from his family and the community service providers. That does not mean that the outcome would have been as good without those services however. The 30% of kids with speech delay who don’t resolve by themselves? Someone has to watch out for those kids, especially since they are numerically the larger group of kids. As an SLP, I make it my job to worry about them.