Clinical Linguistics & Phonetics

ISSN: 0269-9206 (Print) 1464-5076 (Online) Journal homepage: http://www.tandfonline.com/loi/iclp20

Speech-language pathologists’ practices regarding assessment, analysis, target selection, intervention, and service delivery for children with speech sound disorders Sharynne Mcleod & Elise Baker To cite this article: Sharynne Mcleod & Elise Baker (2014) Speech-language pathologists’ practices regarding assessment, analysis, target selection, intervention, and service delivery for children with speech sound disorders, Clinical Linguistics & Phonetics, 28:7-8, 508-531, DOI: 10.3109/02699206.2014.926994 To link to this article: https://doi.org/10.3109/02699206.2014.926994

Published online: 07 Jul 2014.

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Clinical Linguistics & Phonetics, July–August 2014; 28(7–8): 508–531 ß 2014 Informa UK Ltd. ISSN: 0269-9206 print / 1464-5076 online DOI: 10.3109/02699206.2014.926994

Speech-language pathologists’ practices regarding assessment, analysis, target selection, intervention, and service delivery for children with speech sound disorders SHARYNNE MCLEOD1 & ELISE BAKER2 1

Research Institute for Professional Practice, Learning and Education, Charles Sturt University, Bathurst, NSW, Australia and 2Discipline of Speech Pathology, The University of Sydney, Sydney, NSW, Australia (Received 20 January 2014; accepted 23 March 2014) Abstract A survey of 231 Australian speech-language pathologists (SLPs) was undertaken to describe practices regarding assessment, analysis, target selection, intervention, and service delivery for children with speech sound disorders (SSD). The participants typically worked in private practice, education, or community health settings and 67.6% had a waiting list for services. For each child, most of the SLPs spent 10–40 min in preassessment activities, 30–60 min undertaking face-to-face assessments, and 30–60 min completing paperwork after assessments. During an assessment SLPs typically conducted a parent interview, singleword speech sampling, collected a connected speech sample, and used informal tests. They also determined children’s stimulability and estimated intelligibility. With multilingual children, informal assessment procedures and English-only tests were commonly used and SLPs relied on family members or interpreters to assist. Common analysis techniques included determination of phonological processes, substitutions– omissions–distortions–additions (SODA), and phonetic inventory. Participants placed high priority on selecting target sounds that were stimulable, early developing, and in error across all word positions and 60.3% felt very confident or confident selecting an appropriate intervention approach. Eight intervention approaches were frequently used: auditory discrimination, minimal pairs, cued articulation, phonological awareness, traditional articulation therapy, auditory bombardment, Nuffield Centre Dyspraxia Programme, and core vocabulary. Children typically received individual therapy with an SLP in a clinic setting. Parents often observed and participated in sessions and SLPs typically included siblings and grandparents in intervention sessions. Parent training and home programs were more frequently used than the group therapy. Two-thirds kept up-to-date by reading journal articles monthly or every 6 months. There were many similarities with previously reported practices for children with SSD in the US, UK, and the Netherlands, with some (but not all) practices aligning with current research evidence.

Keywords: Assessment, intervention, professional practice, speech-language pathology, speech sound disorders

Introduction This special issue celebrates the contributions of Thomas W. Powell to the field of clinical linguistics and phonetics. One significant area of influence of his work has been to research Correspondence: Sharynne McLeod, PhD, Research Institute for Professional Practice, Learning and Education, Charles Sturt University, Panorama Ave, Bathurst, NSW 2795, Australia. Tel: +61 2 63384463. Fax: +61 2 63384417. E-mail: [email protected]

SLPs’ practices for children with SSD 509 aspects of assessment (Powell, 1997; Powell & Miccio, 1996), analysis (Dinnsen, Chin, Elbert, & Powell, 1990; Elbert, Dinnsen, & Powell, 1984), target selection (Powell, 1991), intervention (Miccio & Powell, 2010; Powell, 1993, 1996, 2008a, b; Powell & Elbert, 1984; Powell, Elbert, Miccio, Strike-Roussos, & Brassuer, 1998), and service delivery (particularly ethical practices, Powell, 2007, 2013) for children with speech sound disorders (SSD). Dr. Powell presented a keynote address to the Speech Pathology Australia National Conference in 2002. His paper began and ended with the charge ‘‘better living through communication’’ (Powell, 2002, p. 26, 34). He indicated that there are many opportunities for involvement, advocacy, and service. The same sentiments continue to be expressed through his writings: ‘‘Speech-language pathologists are encouraged to advocate on behalf of clients by adopting the highest standards of clinical practice and by evaluating treatment options in a systematic, critical, and ethical manner’’ (Powell, 2008a, p. 374). The current paper was written to consider Australian speech-language pathologists’ current practices regarding assessment, analysis, target selection, intervention, and service delivery for children with SSD in order to support the adoption of ‘‘the highest standards of clinical practice.’’ Children with SSD ‘‘can have any combination of difficulties with perception, articulation/ motor production, and/or phonological representation of speech segments (consonants and vowels), phonotactics (syllable and word shapes), and prosody (lexical and grammatical tones, rhythm, stress, and intonation) that may impact speech intelligibility and acceptability’’ (International Expert Panel on Multilingual Children’s Speech, 2012, p. 1). In this paper, the term SSD encompasses speech, articulation and/or phonological impairment, delay, or disorder. Internationally, children with SSD form a substantial portion of speech-language pathologists’ (SLPs) caseloads. In a report on the National Outcome Measure System in the US, Mullen and Schooling (2010) noted that speech sound production was the most frequent area of difficulty for 14 852 students enrolled in speech-language pathology services from K-12. Additionally, 74.7 % of 6624 students in Pre-K were identified with difficulties with intelligibility. In a survey of 489 pediatric SLPs in the US, 52% indicated that children with SSD constituted half or more of their caseloads (Brumbaugh & Smit, 2013). A similar story is told in other countries around the world. In the UK, of 1100 referrals to one speech and language therapy service, 29.1% were identified with speech difficulties (Broomfield & Dodd, 2004). A survey of 98 SLPs in the UK revealed that children with SSD formed more than 40% of the caseloads for more than half the respondents (Joffe & Pring, 2008), 270 Australian SLPs reported that 46.9% of their pediatric caseloads were children with SSD (range 5–100%) (McLeod & Baker, 2004), and, in the Netherlands, a survey of 85 SLPs found that the majority (90%) reported having children with ‘‘articulation problems’’ on their caseloads (Priester, Post, & Goorhuis-Brouwer, 2009). In an ideal world, all children with SSD on SLP caseloads would receive best practice during assessment, analysis, target selection, intervention, and service delivery. Children’s speech intelligibility would be improved prior to starting school and their risk of future academic and socio-emotional difficulties would diminished (e.g. Johnson, Beitchman, & Brownlie, 2010; McCormack, McLeod, McAllister, & Harrison, 2009; Nathan, Stackhouse, Gouldandris, & Snowling, 2004). Internationally, SLP organizations encourage SLPs to make clinical decisions in accordance with the best available evidence within position statements, ethical guidelines, and role and responsibility documents (e.g. American Speech-Language-Hearing Association, 2004; International Expert Panel on Multilingual Children’s Speech, 2012). Evidence-based practice for children with SSD: recommendations from published research Recommendations are available for SLPs on how assessment, analysis, target selection, intervention, and service delivery might be conducted. For example, it is recommended that

510 S. McLeod & E. Baker SLPs elicit a single-word sample of at least 100 words reflecting both a complete inventory of consonants across relevant word positions and a variety of word shapes, lengths, and stress patterns (Bernhardt & Holdgrapher, 2001; Eisenberg & Hitchcock, 2010). Conversational speech samples are also recommended for examining prosody, intelligibility, and interactions between children’s speech production skills and other language abilities (Bernhardt & Holdgrapher, 2001; Morrison & Shriberg, 1992). When assessing multilingual children, it is recommended that the languages spoken by a child be assessed, ideally using language-specific speech sampling tools (International Expert Panel on Multilingual Children’s Speech, 2012). It is also recommended that comprehensive assessments include evaluations of children’s speech sound stimulability (e.g. Glaspey & Stoel-Gammon, 2007; Powell & Miccio, 1996), oromotor structure and function (e.g. Robbins & Klee, 1987), speech perception, receptive vocabulary, phonological awareness, and emergent literacy skills (e.g. Rvachew & Grawburg, 2006), in addition to their overall intelligibility and participation in everyday life (e.g. McLeod, Harrison, & McCormack, 2012). The information garnered from a comprehensive assessment enables thorough analysis. Methods of analysis have included traditional analysis of substitutions, omissions, distortions, and additions (SODA), the identification of phonological processes and patterns (e.g. Hodson, 2004), independent and relational phonological analyses (Stoel-Gammon & Dunn, 1985), and methods based on theories such as non-linear phonology (e.g. Bernhardt & Holdgrapher, 2001; Rvachew & Brosseau-Lapre´, 2012). Although phonological analyses are recommended over only using traditional articulation analysis of substitution, omission, distortion, additions (SODA) for elucidating children’s phonological systems, no particular analysis approach has unanimously been considered the best. Rather, different analyses can be used to yield different insights and, as a consequence, identify different goals or targets (Baker & Bernhardt, 2004; Williams, 2003). Recommendations regarding target selection abound. As Powell (1991) points out, although the traditional approach (i.e., prioritizing earlier developing easier sounds) has been around since the early years of our profession, other approaches exist. For instance, Gierut and colleagues (e.g. Gierut, 2007; Gierut & Hulse, 2010) recommend that complex targets be prioritized for intervention (e.g. later developing non-stimulable sounds that are excluded from a child’s inventory; consonant clusters with small sonority differences). In contrast, Rvachew and Brosseau-Lapre´ (2012), ‘‘strongly recommend against the complexity approach to the selection of treatment goals’’ (p. 656). Instead, Rvachew and colleagues (e.g. Rvachew & Bernhardt, 2010; Rvachew & Brosseau-Lapre´, 2012) recommend a dynamic systems approach based on individual children’s needs. In this approach, a range of new segmental and/or prosodic targets may be introduced (based on multilinear analysis) that stabilize a child’s emerging skills and build on existing strengths. Hodson (2007) offers another approach – the identification and classification of phonological patterns as either primary, secondary, or tertiary, with primary patterns being prioritized over other patterns. Powell (1991) notes that other factors may also be considered by SLPs when prioritizing targets for children, such as the relevance a particular sound to a child and available resources. With regard to intervention, a range of empirically supported approaches exist (Baker & McLeod, 2011a; Williams, McLeod, & McCauley, 2010). In a narrative review of 134 peer reviewed published intervention studies focused on phonological difficulties in children, 46 distinct intervention approaches were identified, with 23 different approaches described in more than one publication (Baker & McLeod, 2011a). Although phonologically based approaches were identified as more efficient than traditional articulation therapy (at least for children with phonological SSD) (Lousada et al., 2013), no specific approach was endorsed as the best (Baker & McLeod, 2011a). This was in part due to limited comparative research reporting outcomes for different approaches and authors recommending some approaches for specific severities or types

SLPs’ practices for children with SSD 511 of SSD (e.g. core vocabulary for inconsistent speech disorder, Crosbie, Holm, & Dodd, 2005). The addition of some components such as speech perception training (Rvachew, Rafaat, & Martin, 1999) has also been recommended to enhance outcomes. However, the inclusion of non-speech oromotor exercises (NSOME) for children with SSD has not been recommended because of the lack of scientific evidence to support their use (Lof & Watson, 2008; McCauley, Strand, Lof, Schooling, & Frymark, 2009). Recommendations regarding service delivery have been conflicting and/or based on limited research. Regarding the agent of intervention, findings from Lancaster, Keusch, Levin, Pring, and Martin (2010) suggest that SLP-delivered intervention may be better than parent-delivered intervention while Eiserman, McCoun, and Escobar (1990) would suggest that (with appropriate training and assistance), parent-delivered intervention can be equally as effective as SLP-delivered intervention. Using National Outcome Measure System (NOMS) data for preschoolers being treated for SSD only, individual therapy seems to be preferred over group therapy (ASHA, 2011). The completion of a structured home program or regular homework is also recommended for maximizing progress (ASHA, 2011; Gu¨nther & Hauvast, 2010). The present wealth of information on the management of SSD in children and state of the research evidence poses a challenge for SLPs. The proclivity of the research base towards lower levels of evidence, the lack of comparative research, and conflicting recommendations means that SLPs do not have clear guidelines about what is best (Baker & McLeod, 2011a, b). Practical resource constraints pose another challenge – large caseloads and limited time means that efficiency of practice (but not necessarily outcome) can prevail over thoroughness and opportunities to engage in knowledge translation (Cook & Odom, 2013; Khan, 2002). It has been suggested that the wealth of choice, the uncertainty about what is best coupled with resource, and time limitations promulgate eclectic practice and drive clinical decisions to be based more on experience and expertise than evidence (Kamhi, 2011; Lancaster et al., 2010). Experience is influenced by the clients, colleagues, and contexts in which clinicians work. Expertise is influenced by clinicians’ knowledge, access, and opportunity to read research, procedural, and problem solving skills in addition to interpersonal skills and attitudes (Kamhi, 1995). Given such multiple influences on professional practice, what do SLPs decide to do when working with children with SSD?

Surveys of SLPs’ practices with children with SSD Over the past decade, SLPs’ practices with children with SSD have been described based on surveys undertaken in countries including the US (Brumbaugh & Smit, 2013; Caesar & Kohler, 2009; Lof & Watson, 2008; Roseberry-McKibbin, Bruce, & O’Hanlon, 2005; Skahan, Watson, & Lof, 2007), the UK (Joffe & Pring, 2008; Mennen & Stansfield, 2006), Australia (McLeod & Baker, 2004; Watts Pappas, McLeod, McAllister, & McKinnon, 2008; Williams & McLeod, 2012), the Netherlands (Priester, Post, & Goorhuis-Brouwer, 2009), and internationally (Jordaan, 2008). These surveys have revealed that SLPs’ assessments typically include administration of a commercial assessment tools, consideration of intelligibility, stimulability, and hearing screening (Skahan et al., 2007). SLPs have been reported to use a range of assessment tools (Joffe & Pring, 2008; McLeod & Baker, 2004; Priester et al., 2009; Skahan et al., 2007) and the most commonly used tools are developed in the countries the SLPs being practiced in. For example, according to Joffe and Pring (2008), the most commonly used assessment tool by the UK sample was the South Tyneside Assessment of Phonology (Armstrong & Ainley, 1988); according to Skahan et al. (2007), the most commonly used assessment tool by the US sample was Goldman Fristoe Test of Articulation (Goldman & Fristoe, 2000); and according to Priester et al. (2009), the most

512 S. McLeod & E. Baker commonly used tool by the Dutch sample was Logo-Art (Baarda, de Boer-Jongsma, & HaasjesJongsma, 2005). Informal or self-made assessments also were reported to be used in Australia (McLeod & Baker, 2004) and the Netherlands (Priester et al., 2009). When working with multilingual children, surveys revealed that SLPs typically used informal assessment procedures or English-only standardized tests (Skahan et al., 2007; Williams & McLeod, 2012) even though speech sound assessments are available in other languages (McLeod & Verdon, in press). When analyzing children’s speech samples, SLPs in the US often analyzed children’s use of phonological processes, completed a phonological analysis of a connected speech sample, and determined a child’s phonetic inventory (Skahan et al., 2007). Over 90% of Australian SLPs used a phonological process analysis and a SODA analysis to determine substitutions, omissions, distortions, and additions (McLeod & Baker, 2004). Few SLPs used computerized analysis procedures (McLeod & Baker, 2004; Skahan et al., 2007). SLPs frequently chose intervention targets based on prioritizing those that impacted intelligibility, stimulable sounds, and using a developmental order of acquisition (Brumbaugh & Smit, 2013; McLeod & Baker, 2004). According to Joffe and Pring (2008), selection of intervention approaches in the UK was influenced by the child’s age, parental attitude (motivation and ability), as well as the child’s language, cognition, ability to listen and to hear. The surveys revealed that SLPs were aware of and used a variety of intervention approaches (Brumbaugh & Smit, 2013; Joffe & Pring, 2008; McLeod & Baker, 2004). Intervention approaches that were frequently used by SLPs in the US survey were the following: traditional articulation approaches, phonological awareness training, minimal pairs, cycles, and whole language approaches (Brumbaugh & Smit, 2013). In another US survey, 85% of 537 SLPs reported that they used NSOMEs during intervention for children with SSD (Lof & Watson, 2008). SLPs in the UK survey most frequently used auditory discrimination, minimal contrast therapy, and phonological awareness intervention (Joffe & Pring, 2008), while SLPs in the Australian survey most frequently used traditional articulation and minimal pairs approaches to intervention (McLeod & Baker, 2004). Service delivery also has been considered in these international surveys. In the US 3- to 6year-old, children with SSD were likely to receive 30 or 60 min of intervention per week in either a group or an individual setting (Brumbaugh & Smit, 2013). In Australia, children with SSD were most likely to have individual sessions with an SLP in the clinic (McLeod & Baker, 2004). SLPs frequently involved parents in assessment (Skahan et al., 2007) and intervention (Joffe & Pring, 2008; Watts Pappas et al., 2008) but were less likely to involve parents in service planning, with a focus on therapist- rather than family-centered practices (Watts Pappas et al., 2008). Collectively, these surveys have provided a snapshot of SLPs’ practices with children with SSD; however, most of these previous surveys have focused on one or two areas of practice (e.g. intervention and service delivery), but have not considered the breadth of practice regarding assessment, analysis, target selection, intervention, and service delivery within the same sample. Consequently, the current research aims to provide an integrated overview of the sequence of clinical decisions from assessment to intervention within the same sample of SLPs.

Aim The primary aim of this research was to describe current practices for Australian SLPs working with children with SSD and contrast these findings with previously published research on SLPs’ practices and recommendations from the published literature.

SLPs’ practices for children with SSD 513 Method Participants Potential participants were a national sample of 322 practising SLPs who attended Speech Pathology Australia seminars conducted in every state and territory in Australia conducted by the first two authors. A total of 231 SLPs completed questionnaires and consented to results being analyzed, indicating a 71.7% response rate. Of the 231 participants, 98.7% were female and 45.9% were parents. Combined, they practiced in every state and territory in Australia. Collectively, the participants had undertaken their professional training in every state in Australia that hosted a speech-language pathology program, as well as in the UK, US, New Zealand, and South Africa. The majority of the 231 participants (47.6%) had been practicing as an SLP for more than 10 years. Of the other participants, 7.8% had practiced for less than 1 year, 16.5% between 1 and 3 years, 16.0% between 4 and 6 years, and 10.4% between 7 and 10 years. The participants were invited to indicate their main area/s of specialization. The major areas were phonological delay/ disorder (53.2%), childhood apraxia of speech (CAS) (19.9%), child language disorder (59.7%), fluency (16.5%), and other (33.3%) (the most common other responses were literacy, autism, and disability). Of the 218 valid responses, there were 54.1% SLPs who worked fulltime and 45.9% who worked part time. Questionnaire A questionnaire was designed to gain an overview of SLPs’ clinical practice with children with SSD. Questions were asked about the SLPs’ demographic details, caseload, assessment and analysis practices, target selection, intervention practices, service delivery, keeping up to date, and working with families. Responses to two other sections of the questionnaire have been described in other papers: the effect SSD on children’s activities and participation (McCormack, McLeod, Harrison, & McAllister, 2010) and knowledge of tongue palate contact for speech production (McLeod, 2011). The initial version of the questionnaire (McLeod & Baker, 2004) was developed via discussions with practicing SLPs and a review of the literature regarding SLP practices for children with SSD. The questionnaire used in the present investigation was slightly modified in order to enable comparisons by incorporating features from the questionnaires used by Skahan et al. (2007), Joffe and Pring (2008), and Watts Pappas et al. (2008). The final sections of the questionnaire were included due to the authors’ current research foci. The listing of factors, assessments, and interventions in Tables 1–7 uses the same wording as the stimuli from the questionnaires.

Procedure The first two authors conducted seminars run by Speech Pathology Australia in every state and territory in Australia. The 1- and 2-day seminars focused on children with SSD, and a total of 322 SLPs attended. Prior to the commencement of each seminar, the participants were invited to complete the comprehensive questionnaire in order to assist the presenters’ understanding of the prior knowledge of the participants, and also to collect national data regarding current practices for children with SSD. Participants were advised to indicate ‘‘not for research’’ if they did not want their responses included in the analysis. They were also asked not to put their name on the questionnaire so that the responses remained anonymous. Speech Pathology Australia gave permission for the questionnaires to be distributed and the research was approved by the Charles Sturt University Ethics in Human Research Committee.

514 S. McLeod & E. Baker Data analysis When participants indicated two responses, the most conservative response was recorded during data entry (e.g. if they circled both always and sometimes, then sometimes was recorded as the response). There were missing data from some participants for almost every question on the questionnaire. Consequently, reported percentages are for valid data; that is, the reported percentage excludes the participants who provided no response on each question. Within the remainder of this paper, only percentages are provided; however, the valid number of responses for each question is indicated within the result tables or within the text if no tables are provided. For most items, descriptive statistics, including frequencies, means, and medians (where appropriate), were calculated.

Results Caseload The participants were asked to indicate the context in which they worked and were able to list more than one context if appropriate. The 220 participants who responded to this question worked in the following settings: private practice (38.1%), education (37.7%), community health (29.0%), hospitals (13.9%), disability (11.3%), university (0.4%), and other (6.1%) (the most common other response was early intervention). Most of 200 participants stated that children with SSD comprised between 10 and 39% (35.5%) or between 40 and 70% (35.5%) of their caseload. The other responses were less than 10% (6.9%), greater than 70% (8.7%), and no response (13.4%). In comparison, there were fewer children on their caseload identified as having childhood apraxia of speech: less than 10% (70.6%), between 10 and 39% (16.9%), between 40 and 70% (0.9%), greater than 70% (0%), and no response (11.7%) (valid responses n ¼ 204). The number of children on 135 participants’ caseloads ranged from one to 500 (the remaining participants did not answer this question). The majority of SLPs (67.6%) had a waiting list for services and 29.4% did not have a waiting list (valid responses n ¼ 210). There were 10.0% participants who indicated that their assessment and/or intervention waiting time was 12 months or greater, with another 5.7% of participants who provided a range that included 12 months (e.g. 9–12 months).

Keeping up to date In response to the question ‘‘how often would you read a journal article/book chapter on articulation and phonology?,’’ the majority of participants indicated monthly (39.8%) and every 6 months (39.8%); while others indicated weekly (1.3%), fortnightly (4.8%) and rarely (11.7%) and no response (2.6%) (valid responses n ¼ 226). In response to an open-ended question to describe the main difficulty associated with keeping up to date, most participants indicated having the time to read the literature. A few participants also described difficulty accessing journal articles, the breadth of their caseload (and, therefore, areas to read about), and difficulty understanding literature that was complex or provided divergent views.

Assessment The SLPs were asked to indicate the amount of time that best described their assessment practices (Table 1). The majority of SLPs spent 30 min or less on pre-assessment activities including completion of paperwork and interviewing teachers/parents. More time was spent on direct

78 (36.8%) 5 (2.3%) 10 (4.7%)

31 (14.6%) 0 (0.0%) 7 (3.3%)

1. Pre-assessment activities including completion of paperwork, interviewing teachers/parents 2. Direct assessment activities with the child including administration of formal and informal assessments 3. Post-assessment data analysis and completion of paperwork for children

11–20 min

5–10 min

Assessment activity

26 (12.3%)

22 (10.3%)

49 (23.1%)

21–30 min

41 (19.3%)

44 (20.7%)

25 (11.8%)

31–40 min

22 (10.4%)

28 (13.1%)

6 (2.8%)

41–50 min

Table 1. Amount of time spent by SLPs during the phases of assessment for children with speech sound disorders (n ¼ 231).

31 (19.3%)

43 (20.7%)

11 (11.8%)

51–60 min

75 (10.4%)

71 (13.1%)

21 (2.8%)

460 min

212

213

212

Valid data

SLPs’ practices for children with SSD 515

1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. 17. 18. 19.

Arizona Articulation Proficiency Scale (Fudala & Reynolds, 1989) Articulation Survey (Aitken & Fisher, 1996) Assessment Link Between Phonology and Articulation (Lowe, 1986) Bankson–Bernthal Test of Phonology (Bankson & Bernthal, 1990) Computerized Articulation and Phonology Evaluation System (CAPES) (Masterson & Bernhardt, 2001) Clinical Assessment of Articulation and Phonology (CAAP) (Secord & Donohue, 2002) Daz Roberts Test of Articulation (Roberts, 2000) Diagnostic Evaluation of Articulation & Phonology (DEAP) (Dodd et al., 2002) Fisher–Logemann Test of Articulation Competence (Fisher & Logemann, 1971) Goldman Fristoe Test of Articulation (Goldman & Fristoe, 2000) Hodson Assessment of Phonological Patterns (Hodson, 2004) Khan–Lewis Phonological Analysis (Khan & Lewis, 2002) Photo Articulation Test (Lippke, Dickey, Selmar, & Soder, 1997) Profiling Elements of Prosodic Systems – Children (PEPS-C) (Peppe´ & McCann, 2003) Scaffolding Scale of Stimulability (SSS) (Glaspey, 2006) Structured Photo Articulation Test (Dawson & Tattersall, 2001) Templin–Darley Tests of Articulation (Templin & Darley, 1969) Conversational speech sampling Informal/home made single word tests

Assessment tool

Table 2. SLPs’ frequency of use of speech assessment tools (n ¼ 231).

1 77 0 0 0 1 17 16 4 10 0 0 1 0 0 0 1 120 38

(0.6%) (38.1%) (0.0%) (0.0%) (0.0%) (0.6%) (9.4%) (8.6%) (2.3%) (5.5%) (0.0%) (0.0%) (0.6%) (0.0%) (0.0%) (0.0%) (0.6%) (58.3%) (21.0%)

Always 0 60 0 1 0 3 26 48 22 40 4 1 1 2 1 0 0 53 69

(0.0%) (29.7%) (0.0%) (0.6%) (0.0%) (1.7%) (14.4%) (25.9%) (12.4%) (21.9%) (2.3%) (0.6%) (0.6%) (1.2%) (0.6%) (0.0%) (0.0%) (25.7%) (38.1%)

Sometimes 2 11 2 7 4 3 15 30 20 39 6 3 3 1 2 1 2 14 25

(1.1%) (5.4%) (1.2%) (4.0%) (7.3%) (1.7%) (8.3%) (16.2%) (11.3%) (21.3%) (3.5%) (1.7%) (1.7%) (0.6%) (1.2%) (0.6%) (1.2%) (6.8%) (13.8%)

Infrequently

172 54 171 165 51 166 122 91 131 94 162 168 168 170 169 173 164 19 49

(98.3%) (26.7%) (98.8%) (95.4%) (92.7%) (96.0%) (67.8%) (49.2%) (74.0%) (51.4%) (94.2%) (97.7%) (97.1%) (98.3%) (98.3%) (99.4%) (98.2%) (9.2%) (27.1%)

Never

175 202 173 173 55 173 180 185 177 183 172 172 173 173 172 174 167 206 181

Valid data

516 S. McLeod & E. Baker

SLPs’ practices for children with SSD 517 Table 3. SLPs’ frequency of use of speech assessment components (n ¼ 231).

Speech assessment components 1. Parent interview + child case history 2. Single word test to determine sounds in error 3. Single word test to determine percentile rank + standard score 4. Phonological analysis of connected speech sample 5. Hearing screening 6. Stimulability of error sounds 7. Perception/discrimination assessment 8. Contextual testing to determine phonetic context effects 9. Classroom observation 10. Determining phonetic inventory 11. Determining phonological processes 12. Determining syllable/word shapes 13. Assessing phonemic awareness skills 14. Assessing oral motor skills using non-speech tasks 15. Assessing oral motor skills using speech tasks 16. Estimating intelligibility

Always

Sometimes

Infrequently

Never

Valid data

196 (89.9%) 192 (88.9%) 21 (11.2%)

17 (7.8%) 23 (10.6%) 49 (26.1%)

4 (1.8%) 1 (0.5%) 61 (32.4%)

1 (0.5%) 0 (0.0%) 57 (30.3%)

218 216 188

68 81 164 32 16

(33.0%) (41.3%) (77.7%) (15.8%) (8.2%)

91 56 37 94 53

(44.2%) (28.6%) (17.5%) (46.3%) (27.3%)

36 14 7 56 65

(17.5%) (7.1%) (3.3%) (27.6%) (33.5%)

11 45 3 21 60

(5.3%) (23.0%) (1.4%) (10.3%) (30.9%)

206 196 211 203 194

19 107 160 40 54 46 52 114

(9.3%) 67 (32.7%) (51.2%) 72 (34.4%) (75.8%) 46 (21.8%) (20.9%) 74 (38.7%) (25.6%) 126 (59.7%) (21.6%) 101 (47.4%) (24.6%) 100 (47.4%) (55.1%) 64 (30.9%)

83 22 3 45 26 53 51 16

(40.5%) (10.5%) (1.4%) (23.6%) (12.3%) (24.9%) (24.2%) (7.7%)

36 8 2 32 5 13 8 13

(17.6%) (3.8%) (0.9%) (16.8%) (2.4%) (6.1%) (3.8%) (6.3%)

205 209 211 191 211 213 211 207

Table 4. SLPs’ frequency of use of assessment methods with children who speak languages other than English (n ¼ 231). Assessment method 1. 2. 3. 4.

English-only standardized test Standardized test in the child’s first language Informal procedures Developed local norms

Always 68 4 114 11

(45.6%) (3.7%) (70.8%) (10.3%)

Sometimes

Infrequently

67 10 38 27

7 9 4 17

(45.0%) (9.3%) (23.6%) (25.2%)

(4.7%) (8.3%) (2.5%) (15.9%)

Never 7 85 5 52

(4.7%) (78.7%) (3.1%) (48.6%)

Valid data 149 108 161 107

Table 5. Factors considered by SLPs when prioritizing intervention targets for children with multiple sounds in error (n ¼ 231). Factor to consider

High priority

Medium priority

Low priority

Valid data

1. Stimulable sounds 2. Early developing sounds 3. Sounds in error in one position only (i.e., correct in other positions) 4. Non-stimulable sounds 5. Later developing sounds 6. Sounds in error across all positions 7. Sounds in the child’s name 8. Sounds the parent/child would like to say 9. Other factors

156 (74.6%) 136 (64.8%) 38 (19.4%)

42 (20.1%) 58 (27.6%) 80 (40.8%)

11 (5.3%) 16 (7.6%) 78 (39.8%)

209 210 196

47 35 128 63 69 24

91 72 61 94 98 35

56 84 8 44 31 16

194 191 197 201 198 75

(24.2%) (18.3%) (65.0%) (31.3%) (34.8%) (32.0%)

(46.9%) (37.7%) (31.0%) (46.8%) (49.5%) (46.7%)

(28.9%) (44.0%) (4.1%) (21.9%) (15.7%) (21.3%)

1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. 17. 18. 19. 20. 21. 22. 23. 24. 25. 26. 27. 28. 29.

Auditory bombardment (e.g. Hodson & Paden, 1991) Auditory discrimination (e.g. Berry & Eisenson, 1956) Core vocabulary (e.g. Dodd & Bradford, 2000) Cued articulation (e.g. Passey, 1990) Cycles (e.g. Hodson & Paden, 1983) Dynamic temporal and tactile cueing (e.g. Strand, Stoeckel, & Baas, 2006) Imagery approach (e.g. Klein, 1996) Instrumental approaches (e.g. electropalatography; ultrasound, Hardcastle & Gibbon, 1997) Maximal oppositions contrast (e.g. Gierut, 1990) Metaphon (e.g. Howell & Dean, 1994) Metaphonological intervention (e.g. Hesketh, Adams, Nightingale & Hall, 2000) Minimal opposition contrast (minimal pairs) (e.g. Weiner, 1981) Mnemonic approach (Young, 1995) Multiple opposition contrast (e.g. Williams, 2000) Natural speech intelligibility training (e.g. Camarata, 2010) Non-linear phonological intervention (e.g. Bernhardt & Stemberger, 2000) Non-speech oromotor intervention (e.g. Lancaster & Pope, 1989) Nuffield Centre Dyspraxia Programme (e.g. Nuffield Hearing & Speech Centre, 2004) Parents and Children Together (e.g. PACT) (e.g. Bowen & Cupples, 1999) Phonological awareness (e.g. Gillon, 2000) Phonotactic therapy (e.g. Velleman, 2002) Prompts for Restructuring Oral Muscular Phonetic Targets (e.g. PROMPT) (e.g. Hayden, 2006) Psycholinguistically based intervention (e.g. Stackhouse & Wells, 1997) SAILS perceptual intervention (e.g. Rvachew, 1994) Suck–swallow–breathe synchrony (e.g. Oetter, Richter, & Frick, 1993) Traditional articulation therapy (e.g. van Riper, 1939) Treatment program for enhancing stimulability (e.g. Miccio, 2005) Whole language therapy (e.g. Hoffman, Norris, & Monjure, 1990) Other

Intervention approach

Table 6. SLPs’ frequency of use of speech intervention approaches (n ¼ 231).

39 (19.9%) 67 (33.5%) 16 (8.3%) 63 (30.7%) 8 (4.3%) 6 (3.4%) 4 (2.2%) 0 (0.0%) 11 (6.0%) 6 (3.3%) 5 (2.9%) 61 (31.3%) 2 (1.1%) 9 (5.1%) 3 (1.8%) 4 (2.3%) 3 (1.6%) 23 (11.6%) 8 (4.5%) 52 (26.0%) 3 (1.8%) 13 (7.0%) 2 (1.1%) 0 (0.0%) 0 (0.0%) 47 (23.4%) 2 (1.1%) 5 (2.7%) 2 (0.9%)

Always (44.4%) (55.5%) (56.0%) (42.4%) (27.6%) (10.2%) (13.3%) 0 (0.0%) 70 (38.0%) 64 (34.8%) 18 (10.5%) 114 (58.5%) 7 (4.0%) 46 (26.0%) 9 (5.3%) 19 (11.0%) 32 (17.2%) 112 (56.3%) 30 (16.9%) 103 (51.5%) 11 (6.4%) 25 (13.5%) 23 (13.2%) 0 (0.0%) 1 (0.6%) 117 (58.2%) 13 (7.3%) 43 (23.4%) 8 (3.5%)

87 111 108 87 51 18 24

Sometimes 40 (20.4%) 15 (7.5%) 38 (19.7%) 33 (16.1%) 47 (25.4%) 21 (11.9%) 25 (13.9%) 2 (1.1%) 47 (25.5%) 35 (19.0%) 22 (12.8%) 12 (6.2%) 17 (9.7%) 28 (15.8%) 19 (11.1%) 28 (16.3%) 35 (18.8%) 46 (23.1%) 28 (15.8%) 31 (15.5%) 22 (12.9%) 21 (11.4%) 28 (16.1%) 4 (2.3%) 9 (5.1%) 23 (11.4%) 12 (6.8%) 32 (17.4%) 1 (0.4%)

Infrequently 30 (15.3%) 7 (3.5%) 31 (16.1%) 22 (10.7%) 79 (42.7%) 132 (74.6%) 127 (70.6%) 176 (98.9%) 56 (30.4%) 79 (42.9%) 127 (73.8%) 7 (3.6%) 149 (85.1%) 94 (53.1%) 140 (81.9%) 121 (70.3%) 116 (62.4%) 18 (9.0%) 111 (62.7%) 14 (7.0%) 135 (78.9%) 126 (68.1%) 121 (69.5%) 169 (97.7%) 166 (94.3%) 14 (7.0%) 150 (84.7%) 104 (56.5%) 55 (23.8%)

Never

196 200 193 205 185 177 180 178 184 184 172 195 175 177 171 172 186 199 177 200 171 185 174 173 176 201 177 184 66

Valid data

518 S. McLeod & E. Baker

1. Do you feel that family involvement affects the outcomes of your intervention for speech sound disorders? 2. Do parents/other family members observe your intervention sessions for their child with a speech sound disorder? 3. Do you ask parents/other family members to participate in your intervention sessions for speech sound disorders? 4. Do you give homework activities to parents/other family members in your intervention for speech sound disorders? 5. Do you have difficulty involving families as much as you would like in intervention for speech sound disorders? 6. Are you influenced by the family regarding how you involve them in intervention for speech impairment? 7. Do you typically involve siblings in assessment and intervention? 8. Do you typically involve grandparents in assessment and intervention?

Question 36 (17.1%) 63 (29.9%) 72 (34.0%) 55 (25.9%) 35 (16.6%) 81 (38.9%) 127 (72.6%) 128 (74.0%)

111 (52.6%) 103 (48.6%) 150 (70.8%) 19 (9.0%) 51 (24.5%) 4 (2.3%) 2 (1.2%)

Usually

171 (81.4%)

Always

44 (19.0%) 43 (18.6%)

69 (29.9%)

133 (57.6%)

6 (2.6%)

30 (13.0%)

31 (13.4%)

3 (1.3%)

Sometimes

Table 7. SLPs’ frequency of family involvement in assessment and intervention for children with speech sound disorders (n ¼ 231).

0 (0.0%) 0 (0.0%)

4 (1.9%)

19 (9.0%)

1 (0.5%)

5 (2.4%)

3 (1.4%)

0 (0.0%)

Rarely

0 (0.0%) 0 (0.0%)

3 (1.4%)

5 (2.4%)

0 (0.0%)

2 (0.9%)

3 (1.4%)

0 (0.0%)

Never

175 173

208

211

212

212

211

210

Valid responses

SLPs’ practices for children with SSD 519

520 S. McLeod & E. Baker assessment activities with the child including administration of formal and informal assessments; 67.6% of the participants indicated they spent 30 min or more on the direct assessment. Postassessment data analysis and completion of paperwork for children took 30 min or more for 59.4% of the participants. The SLPs used a wide variety of assessment tools to assess children with SSD (Table 2). The majority indicated that they always (58.3%) or sometimes (25.7%) used conversational speech sampling. Additionally, participants always (21.0%) or sometimes (38.1%) used informal/homemade single word tests. Fourteen of the 17 listed commercially available tests of articulation and phonology were used always or sometimes by at least one of the participants. The most commonly used commercially available tests were those with Australian normative data: Articulation Survey (Aitken & Fisher, 1996) (always 38.1% and sometimes 29.7%), Daz Roberts Test of Articulation (Roberts, 2000) (always 9.4% and sometimes 14.4%), Diagnostic Evaluation of Articulation and Phonology (DEAP) (Dodd et al., 2002) (always 8.6% and sometimes 25.9%), as well as the Goldman Fristoe Test of Articulation (Goldman & Fristoe, 2000) (always 5.5% and sometimes 21.9%) that has norms from the US. Participants were provided with a list of 16 components of speech assessments and were asked to indicate whether these were used always, sometimes, infrequently, or never (Table 3). Six components of speech assessments were regularly undertaken by the SLPs: parent interview + child case history (89.9% always), single word test to determine sounds in error (88.9% always), determining stimulability of error sounds (77.7% always), determining phonological processes (75.8% always), estimating intelligibility (55.1% always), and determining phonetic inventory (51.2% always). The most common components that were never used by at least 20% of participants were contextual testing to determine phonetic context effects (30.9% never), single word test to determine percentile rank and standard score (30.3% never), and hearing screening (23.0% never).

Speech assessment with multilingual children Of the 203 SLPs who responded to questions about assessing the speech of children who ‘‘speak English as a second or other language’’ (Table 4), there was a median of 5.0% (mean ¼ 9.8%, range ¼ 0–90%) on their caseload. The major methods used by the participants when assessing multilingual children were to use informal procedures (70.8%) and/or an English-only standardized test (45.6%) (Table 4). Very few used standardized tests in the child’s first language. SLPs were asked to indicate who typically assisted them when assessing the speech skills of these children when they are not familiar with the child’s native language. The most common response was that the child’s family member translated (55.9%), or that an interpreter was provided by the workplace (38.4%). Less frequent responses were that the SLPs worked with another SLP (colleague) (13.6%), an English as a second language (ESL) teacher (12.4%), someone else (8.3%), or no one (5.1%).

Analysis The SLPs were invited to check as many different analysis methods they used for analyzing the speech of children with SSD from a list of seven possibilities. Of the 217 SLPs who responded to this question, the majority used a phonological process analysis (96.3%) and a SODA analysis to determine substitutions, omissions, distortions, and additions (94.0%). Fewer SLPs used an independent and relational analysis (13.4%), psycholinguistic analysis (7.4%), non-linear analysis (4.1%), or other analyses (6.0%). The majority (97.7%) of 219 SLPs did not use computerized analysis procedures for articulation/phonology assessment with only 2.3% saying that they did and Computerized Profiling (Long & Fey, 1993) was the preferred computerized analysis tool.

SLPs’ practices for children with SSD 521 Target selection The SLPs were invited to respond to the following question ‘‘When prioritizing intervention targets for children with multiple sounds in error, what priority do you give to the following factors’’ and were provided with nine options (Table 5). The majority of participants placed a high priority on stimulable sounds (74.6%), early developing sounds (64.8%), and sounds in error across all positions (65.0%). The SLPs placed a medium priority on sounds the parent/child would like to say (49.5%), sounds in the child’s name (46.8%), and sounds in error in one position only (40.8%), and a low priority on later developing sounds (44.0%). The SLPs were invited to answer the following question on a scale from one (very confident) to five (not at all confident): ‘‘How confident do you feel about choosing an appropriate treatment option when planning a therapy program for a client with phonological delay/disorder?’’ There were 209 responses to this question. Although few SLPs felt very confident (6.2%), half indicated that they felt confident (54.1%) choosing an appropriate treatment. Other responses were neutral (29.2%), not very confident (10.0%), not at all confident (0.5%). It is important to note that 12 people circled both confident and neutral, and these were analyzed as ‘‘neutral’’ (to be conservative). Next the participants were asked to respond to the statement ‘‘I feel there is sufficient evidence to show that intervention with phonological disordered clients is effective.’’ There were 14.7% of the SLPs who indicated that they strongly agreed, 57.3% agreed, 19.4% neither agreed nor disagreed, 8.1% disagreed, and 0.5% strongly disagreed.

Intervention The SLPs reported that they used a wide variety of intervention approaches for children with SSD (Table 6). There were eight approaches that were frequently used with children with SSD: auditory discrimination (33.5% always and 55.5% sometimes) (e.g. Berry & Eisenson, 1956), minimal opposition contrast (minimal pairs) (31.3% always and 58.5% sometimes) (e.g. Weiner, 1981), cued articulation (30.7% always and 42.4% sometimes) (e.g. Passey, 1990), phonological awareness (26.0% always and 51.5% sometimes) (e.g. Gillon, 2000), traditional articulation therapy (23.4% always and 58.2% sometimes) (e.g. van Riper, 1963), auditory bombardment (19.9% always and 44.4% sometimes) (e.g. Hodson & Paden, 1991), Nuffield Centre Dyspraxia Programme (11.6% always and 56.3% sometimes) (e.g. Nuffield Hearing & Speech Centre, 2004), and core vocabulary (8.3% always and 56.0% sometimes) (e.g. Dodd & Bradford, 2000). There were 17 approaches that were never used by at least 50% of the respondents (Table 6).

Service delivery The participants were asked to indicate all the different service delivery options that they used from a list addressing mode (individual therapy, group therapy, parent training, and home programs), location (clinic, preschool/school, client’s home, and other), and people (clinician, parent/guardian, teacher, teacher’s aide, and interpreter). There were valid data for 210 respondents. The most typical service delivery model was individual therapy (95.7%), followed by parent training (68.6%), and home programs (64.8%). Group therapy was used by one-third of the respondents (36.7%). The major intervention provider was the SLP (clinician) (91.4%), closely followed by the parent/guardian (88.6%). Teachers (36.2%), teachers’ aides (44.8%), and interpreters (5.2%) provided intervention less frequently. The most common place where intervention occurred was in the SLP clinic (73.8%) followed by the preschool/school (57.6%) and the child’s home (25.2%). Other (2.9%) places were infrequently used.

522 S. McLeod & E. Baker Family involvement Eight questions, based on Watts Pappas et al. (2008), were asked to determine SLPs’ perspectives on family involvement in assessment and intervention for children with SSD (Table 7). The majority indicated that family involvement always (81.4%) or usually (17.1%) affects the outcomes of intervention for SSD. The majority of SLPs always (52.6%) or usually (29.9%) had parents/family members observing intervention sessions, and always (48.6%) or usually (34.0%) asked parents/family members to participate in intervention sessions for SSD. Homework activities were always (70.8%) or usually (25.9%) given during intervention for SSD. Approximately half of the SLPs sometimes (57.6%) had difficulty involving families as much as they would like in intervention for SSD (Table 7). Siblings were usually (72.6%) or sometimes (19.0%) involved in assessment and intervention sessions. Similarly, grandparents were usually (74.0%) or sometimes (18.6%) involved in assessment and intervention sessions (Table 7). The participants were asked to indicate who they believed was the client in their intervention for SSD and 211 participants indicated the child (41.2%), the family (40.3%), or both (16.9%). When asked ‘‘Who do your intervention goals focus on in your intervention for speech impairment?,’’ 207 participants responded: the child (59.4%), the family (20.8%), or both (17.7%). The majority of 177 respondents (78.5%) agreed with the philosophy that ‘‘A familycentered approach to early intervention asks SLPs to attend to families’ priorities for goals and services even if they do not agree with them.’’ Finally, the participants were provided with a description of four models of working with families (based on Watts Pappas, McLeod, & McAllister, 2009) and were asked to indicate their usual form of practice when working with families of children with SSD (Table 8). The 204 respondents to this question indicated that they were more likely to use family-friendly (42.6%) and parent-as-therapist aide (40.7%) approaches to intervention than family-centered (16.2%) or therapist-centered (14.2%) approaches.

Discussion This survey of 231 Australian SLPs was undertaken to describe practices regarding assessment, analysis, target selection, intervention, and service delivery for children with SSD. There were many similarities with previously reported practices for children with SSD in the US, UK, and the Netherlands, with some (but not all) practices aligning with evidence-based recommendations. In this discussion, we compare our findings with previous survey research and identify

Table 8. SLPs’ usual form of practice when working with families of children with speech sound disorder (based on Watts Pappas et al., 2009) (n ¼ 231).

Model Therapist-centred Parent-as-therapist aide Family-centred Family-friendly a

Parent involvement in intervention provision Limited Yes Varies according to parents’ wishes Varies according to parents’ wishes

Parent involvement in intervention planning

Primary decisionmaker

No No Yes

SLP SLP Parent

Yes

SLP

SLPs’ usual form of practicea

Valid data

Child Child Family

29 (14.2%) 83 (40.7%) 33 (16.2%)

204 204 204

Varies according to parents’ wishes

87 (46.6%)

204

Primary client

The percentages add to 4100% because some participants indicated more than one ‘‘usual form of practice.’’

SLPs’ practices for children with SSD 523 areas of practice that align with and differ from recommendations. We acknowledge the limitations of our study and offer future directions for addressing gaps between research and practice.

Assessment More than half of the Australian (Aus) SLPs always conducted a parent interview, single word test, examined stimulability of error sounds, conversational speech sampling, and evaluation of intelligibility. In contrast to the findings of Skahan et al. (2007), the Australian SLPs used the following assessment procedures to a greater extent: administered single word tests (US ¼ 74.1% always and Aus ¼ 88.9% always) and examined stimulability (US ¼ 68.0% always and Aus ¼ 77.7% always) (Table 3). There were a few areas where Australian SLPs were less likely to undertake an activity than their US counterparts: estimating intelligibility (US ¼ 75.4% always and Aus ¼ 55.1% always), conducting hearing screening (US ¼ 70.6% always and Aus ¼ 41.3% always), assessing oral motor skills using non-speech tasks (US ¼ 57.6% always and Aus ¼ 21.6% always), assessing oral motor skills using speech tasks (US ¼ 54.4% always and Aus ¼ 24.6% always), and classroom observation (US ¼ 30.7% always and Aus 2009 ¼ 9.3% always). These differences in undertaking hearing screening may be related to the availability of audiologists to undertake hearing screening in Australia. Fewer instances of classroom observation may be related to the differences in service delivery models between the countries, since in the US, half (56%) of all speech-language pathology services are provided in educational settings (Brown & Hasselkus, 2008). Internationally, SLPs frequently use single-word tests in English with a preference for assessments that are created and normed locally. Similarly, the Australian participants preferred to use assessments created in Australia. Indeed, the use of two of the tests was localized to participants residing in the Australian states where they were developed and normed: Articulation Survey (Aitken & Fisher, 1996) was predominantly used in Victoria and the Daz Roberts Test of Articulation (Roberts, 2000) was predominantly used in Tasmania. For children who speak languages other than English, SLPs typically use informal measures and rely on family members for interpreting. This finding was similar to international studies (e.g. Jordaan, 2008). In light of practice recommendations, particularly with respect to gathering samples of at least 100 words and using sampling tools relevant to multilingual children, some disparities were evident.

Analysis The majority of SLPs in the study reported analyzing phonological processes (96.3%) or undertaking SODA analyses (94.0%). Other types of analyses were infrequently or never used, with the majority never using computer-based analysis procedures. Given that such options have been available for over a decade (e.g. Bernhardt & Stemberger, 2000; Long & Fey, 1993), reasons for SLPs’ methods of analysis practice ought to be explored. Rvachew and BrosseauLapre´ (2012) suggest that SLPs opt for familiar analysis methods because they can complete them quickly, and because they do not feel capable of using other methods. With training and experience, however, other comprehensive methods can become efficient, yielding other insights into children’s phonological systems (Baker & Bernhardt, 2004; Long, 2001; Rvachew & Brosseau-Lapre´, 2012). Comparison research is needed to determine whether infrequently used analysis methods yield better outcomes in everyday clinical practice compared with SLPs’ usual practice.

524 S. McLeod & E. Baker Target selection McLeod and Baker (2004) reported that the majority of SLPs gave a high priority to selecting phonemes or phonological processes in keeping with the traditional developmental approach. In McLeod and Baker (2004) (indicated by Aus 2004), 93.7% prioritized stimulable sounds and 86.8% prioritized early developing phonemes. The Australian SLPs in the present study were not as strongly aligned with the traditional developmental approach to target selection. For example, fewer SLPs prioritized stimulable sounds (Aus 2004 ¼ 93.7% high priority and Aus ¼ 67.5% high priority) and early developing sounds (Aus 2004 ¼ 86.8% high priority and Aus ¼ 58.9% high priority); whereas more SLPs prioritized non-stimulable sounds (Aus 2004 ¼ 8.9% high priority and Aus 2009 ¼ 20.3% high priority) and later developing sounds (Aus 2004 ¼ 4.8% high priority and Aus ¼ 15.2% high priority). There was a similar response to the prioritization of sounds in error across all positions (Aus 2004 ¼ 59.6% high priority and Aus ¼ 55.4% high priority). Similar questions regarding target selection were not asked of SLPs in the UK (Joffe & Pring, 2008) or US (Skahan et al., 2007), so direct comparisons cannot be made. However, Joffe and Pring (2008) did indicate that the primary factors influencing UK SLPs choice of therapy were the child’s age (56/98 respondents), parent’s motivation, or ability to assist their children (55/98). Other factors were the child’s speech severity (39/98), language (21/98), listening ability (29/98), cognitive abilities (17/98), and hearing (9/98). They commented ‘‘These factors appear to outweigh detailed assessment of the child’s phonological skills’’ (p. 159), with the exception being ‘‘speech severity.’’ Disparate theoretical orientations across the different target selection approaches make it a controversial and confusing area. According to Garb (1998), clinicians tend to make clinical decisions based on their knowledge and skills when the literature and their experience are at odds. It would seem that if the area is to move forward, then the disparities across the approaches need to be resolved through comparison research.

Intervention Regarding the range and types of intervention approaches used, there were similarities and differences with previous research. For instance, of the eight frequently used approaches (auditory discrimination, minimal pairs, cued articulation, phonological awareness, traditional articulation therapy, auditory bombardment, Nuffield Centre Dyspraxia Programme, and core vocabulary), two of the approaches (minimal pairs and phonological awareness training) were also reported to be frequently used in the UK (Joffe & Pring, 2008) and US (Brumbaugh & Smit, 2013) surveys, one (auditory discrimination) also was also frequent in the UK survey, while another (traditional articulation therapy) was frequent in the US survey. Previous reports about SLPs’ use of NSOMEs indicated high usage; for example, 85% use in a US survey (Lof & Watson, 2008), 85% use in a Canadian survey (Hodge, Salonka, & Kollias, 2005); used often/always (17.4%) or sometimes (54.1%) in UK survey (Joffe & Pring, 2008). However, their use was lower in the current study (always 1.6% and sometimes 17.2%) and in keeping with the declining trend reported by Brumbaugh and Smit (2013). Overall, what do these findings suggest about SLPs’ conduct of evidence-based practice? The range of approaches suggests that the SLPs were using different approaches with children and/or blending approaches in an eclectic manner. During the course of the seminars, the SLPs often commented that they used an eclectic approach to intervention (cf. Kamhi, 1999; Lancaster et al., 2010). Unfortunately, the questionnaire did not specifically include a question about whether SLPs provided intervention techniques as described by the creators or whether they blended approaches. While we are not suggesting that eclectic practice is inconsistent with good practice

SLPs’ practices for children with SSD 525 (Lancaster et al., 2010), the types of approach used as a part of that practice should have an empirically sound foundation. Of the interventions listed in the questionnaire, some older approaches, and some approaches with minimal and/or low levels of evidence were preferred (e.g. traditional articulation therapy [23.4% always] and cued articulation [30.7% always]) over more recent approaches with higher levels of evidence (e.g. cycles [68.1% infrequent or never]; multiple oppositions [68.9% infrequent or never]; metaphonological intervention [86.6% infrequent or never]; SAILS perceptual intervention [100% infrequent or never]). What motivates SLPs to use some approaches over others? Kamhi (1999) suggests that clinicians’ intervention choices are guided by familiarity and successful experience. Although these are admirable and ethical motivations (i.e., you should use what works), empirical foundations matter. If clinicians know that there is another approach that is more effective than their current approach, they are ethically bound to ‘‘try out the new approach to see if it is in fact more effective’’ (Kamhi, 1999, p. 94). While this sentiment promotes evidence-based practice, the translation of knowledge into action is more complicated (Straus, Tetroe, & Graham, 2013).

Service delivery and family involvement The SLPs’ common methods of service delivery (individual therapy [95.7%] with the clinician [91.4%] in the clinic [73.8%]) were consistent with previous reports of Australian SLPs by McLeod and Baker (2004). The findings did, however, contrast with Brumbaugh and Smit (2013, p. 310) where services were typically delivered in ‘‘preschools, early childhood centers, and schools, with some intervention delivered in homes,’’ in individual, group, or a combination of individual and group formats. These differences reflect legislative and policy differences between Australia and the US (McLeod, Press, & Phelan, 2010). Comparison with previous research regarding intensity (session duration, frequency, and total number of sessions) was not possible, as questions about scheduling were not included in the current study. Families (including parents, siblings, and grandparents) were often involved by observing or participating in intervention sessions and/or completing homework activities. This resonated with the SLPs preferences for a family-friendly (42.6%) or parent-as-therapist aide (40.7%) approach. More than half of the respondents sometimes had difficulty involving parents as much as they would like – a finding consistent with Watts Pappas et al. (2008).

Limitations and future research The sample comprised SLPs who were attending a 2-day update seminar on children with SSD, so was not necessarily typical of all practicing SLPs in Australia. Thus, the results of this survey may not represent the views of practicing SLPs who either did not need to be updated, or did not have the time, desire, or funds to attend the seminar. In addition, some aspects of clinical practice were not examined in the questionnaire including eclectic approaches to intervention and intensity. Given recent research identifying intensity as critical to progress (Allen, 2013; Williams, 2012), future research is needed to examine this important aspect of practice. Finally, questionnaire data always carry an element of bias – respondents can over-estimate what they do (Adams, Soumerai, Lomas, & Ross-Degnan, 1999). If we are to better understand what is actually done and why, future research could review SLPs methods of practice through direct observation and interview. A part of this research could examine the challenges involved in knowledge translation, including the barriers that underlie SLPs’ use of relatively less effective or efficient methods, when there are alternate methods available. Discoveries and innovations emerging from the field of

526 S. McLeod & E. Baker implementation science could also be used to translate empirical knowledge into action, and ultimately better outcomes for children with SSD.

Conclusion Thomas W. Powell exhorted ‘‘adopting the highest standards of clinical practice and (by) evaluating treatment options in a systematic, critical, and ethical manner’’ (Powell, 2008a, p. 374). The results from our survey of SLPs methods of practice suggest that if SLPs are to do this, there is a need to better understand the day-to-day challenges and competing demands on SLPs’ time to provide highest standards of practice with limited resources. We also need to identify and adopt implementation strategies that better translate empirical knowledge into action.

Acknowledgements The authors would like to thank Speech Pathology Australia for allowing these questionnaires to be distributed and Madeline Hastings and Hannah Wilkin for their assistance with data entry.

Declaration of interest The authors declare no conflicts of interest. The first author also acknowledges assistance from the Australian Research Council Future Fellowship (FT0990588) and both authors acknowledge assistance from Australian Research Council Discovery Grant (DP130102545).

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Speech-language pathologists' practices regarding assessment, analysis, target selection, intervention, and service delivery for children with speech sound disorders.

A survey of 231 Australian speech-language pathologists (SLPs) was undertaken to describe practices regarding assessment, analysis, target selection, ...
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