Speech and language therapists are employed by health boards and voluntary agencies to assess, diagnose and provide therapy for clients who present with communication and/or swallowing disorders. Disorders of speech, language and communication generally make it difficult for people to express themselves and/or to understand the spoken or written word. The role of the speech and language therapist is to provide therapy for people with communication disorders, and to help their carers develop coping strategies to eliminate or minimise speech, language and related problems.
It is estimated that communication disorders will affect one in ten of the general population at some stage of their lives. This figure increases greatly when language-learning is hindered by factors such as cognitive, physical or sensory impairment. Research on the communication needs of children and adults with learning difficulties indicates that as many as 70% would benefit from speech and language therapy in order to facilitate the development of communication skills. A further 5% may require therapy for swallowing difficulties.
Communication impairment occurs when communication skills fail to develop in an age-appropriate manner or within the typical time-frame, or when skills already developed are lost. Any or all of the many components of language may be impaired. Speech and language therapists diagnose or classify the communication disability by the areas showing the most significant impairment or contributing to the greatest handicap. Thus parents whose child is slow to learn word meanings and/or grammar rules of a language may be told that she has a developmental language impairment or delay. Children who present with atypical developmental patterns may be diagnosed as having specific language impairment (SLI), sometimes also referred to as language disorder, or aphasia / dysphasia. The terms aphasia and dysphasia are, however, more commonly used where language has been acquired and is lost following illness or brain injury.
Some children may grasp word meanings and basic grammar rules, but experience difficulties in mastering the speech sound rules of their native language, resulting in low speech intelligibility. Speech sound difficulties may occur as a result of difficulties in coordinating the muscle movements needed for speech (articulation disorder), but they may also occur when a child finds it difficult to grasp the sound rules of the language (phonological disability). Disorders of voice and swallowing may also occur, owing to difficulties in muscular coordination of the oral and vocal mechanisms. Communication impairment may be represented by difficulties in using language effectively in interpersonal communication (pragmatic disability). Disorders of fluency such as stuttering may reduce the efficacy of speech as a channel for communication.
Surveys in Ireland have indicated that 71% of clients attending special education facilities and adult centres were perceived by frontline staff as being in need of speech and language therapy for the range of communication disorders indicated in the graph below (Communication Needs 1989).
The speech and language therapy process
Speech and language therapy services vary in the way in which services are delivered to clients, according to the policies of the overall service providers (e.g. health boards or voluntary agencies). But the process as outlined below will be common to most. What can happen at the different stages in the process will also vary depending on factors such as the client’s needs, type of communication impairment, availability of staff, service priorities, etc., but the steps as outlined below may be of help to clients and carers currently entering services.
Referral: Referral policies vary greatly between service agencies, and readers are advised to check local policies by contacting the local Principal Speech and Language Therapist. Unfortunately, owing to the large caseloads carried by most speech and language therapists, a waiting period will usually follow the referral before the client can be seen for assessment.
The initial assessment will usually be a screening procedure to determine whether a communication impairment is present; the type of impairment; and how this is affecting on the client and his/ her family/ carers/ teachers, etc. If a significant gap is evident between the client’s communication needs and her/his skills, then detailed assessment is indicated.
A diagnostic assessment will include procedures to evaluate current functioning in all areas of communication. These procedures may be formal tests such as picture identification to assess the client’s understanding of words, sentence structure, etc., or therapists may use questionnaires designed to gather information from parents and those who are most familiar with the client’s communication system. Diagnostic testing and detailed information from the client and/or her communication partners will enable the therapist to identify the areas to be focused on in therapy and will also provide information on the most appropriate form of service delivery.
The goal of speech and language therapy is to enable clients to develop and utilise skills which will enable them to participate and communicate in the social, educational and vocational life of their community. This goal may be best achieved through varying service delivery formats. For some clients individual therapy with a direct focus on their current communication skills and needs will be appropriate. This may involve clients working with the therapist on a one-to-one basis to master the rules of the language. Programmes of this type will, however, be dependent for their success on parents, teachers and others working with the client, sharing and working towards the same goal. Where clients with similar communication skills and needs share daily educational, social or vocational activities, therapy may be delivered in a group setting.
For many clients the use of indirect therapy is an appropriate way to minimise speech, language and communication-related problems, and to maximise the opportunities for communication development in the client’s environment. In indirect therapy, therapists will focus on the communication environment and work with parents and carers to provide and utilise opportunities for the client to communicate and develop new skills. These programmes focus on developing the knowledge and the skills of communication partners to enable them to bring about significant changes in daily life. Indirect therapy may offer parents and carers an individualised programme focused on one client, or may have a more general focus that can be shared by a group. Early intervention programmes such as the Hanen are examples of this type of therapy. In these programmes parents learn strategies both from the formal programme and from each other that enable them to use everyday routines and situations to develop interaction and early communication skills.
The above service delivery models are not mutually exclusive and a client’s therapy programme may include two or more options at the same time. All therapy programmes, regardless of the delivery model employed, will involve a final reassessment to review progress. This is necessary for both the client and the service. The reassessment will indicate what gains have been made by the client during therapy and will also indicate what new goals should be set. Information from reassessment provides therapists and the service with data on the efficacy of therapy, and thus fosters the development of more effective programmes.
Speech and language therapy services
Speech and language therapists are committed to enabling people with communication disorders to participate fully in community life by the provision of appropriate therapy programmes.
Current staffing levels undermine this commitment and result in many difficulties in service planning and development. The table below, which is based on IASLT (1993) estimates, shows the shortfall between the 818 therapists needed to provide a service for the Irish population and the 256 full-time-equivalent posts available in the health services. There are no speech and language therapists employed by the education services.
This shortfall results in service restrictions for all client groups, but services for people with learning difficulties are facing more restrictions owing to the exodus of senior staff from the profession in recent years. However, even within the present restricted services many innovations and new therapy programmes are being developed.
Communication impairment carries a high personal cost and is too important to ignore. Speech and language impairments can affect every aspect of daily life, isolating a person from their community and frustrating efforts to learn and develop. If you or someone for whom you care has difficulty in speaking or understanding you should explore the possibility of referral to your local service. Waiting lists may be long, but your local speech and language therapy service may be able to provide you with coping, teaching and therapy strategies that will eliminate or minimise the impact of speech, language, and related communication impairments.
The professional association is aware of the shortfall in services and has identified the need for the development of specialised services for both adults and children with learning disabilities in many discussion documents, and more recently in presentations to the Labour Court Expert Group which is currently deliberating on the future of the profession. Hopefully these reports will be acted on in the new millennium with services developed to serve the varied needs of clients.