This is the story of when a journal article broke the SLP internet.
And it was kind of a good thing, and kind of a bad thing, and mostly just really confusing to everyone observing it.
So allow me to play out this series of events—trust me, it’s relevant to why someone would ask the question above!
This fall, McLeod and Crowe published this article. Here's a paraphrase of our review of the article:
"This study provides a cross-linguistic review of children’s acquisition of consonants in 27 languages. The authors reviewed 64 studies from 31 countries to inform practicing SLPs’ expectations of children’s speech sound development across languages… SLPs can use this information and the overall patterns of speech sound development to decide what is “typical” across languages and to inform their clinical decisions.”
Sounds great for SLPs working with non-English-speaking children, right? What a great cross-linguistic resource! And when we sent our review to the authors (that’s part of our internal audit process) they said Yep, yep, looks good! And we published it.
Then all hell broke loose. Not because of our review. But because the authors released infographics describing their data. Here’s the infographic set that put U.S.-based SLPs in a tizzy.
Now, here’s what SLPs thought this was:
So! We have some things to talk about here. I’ll try to group them into question themes, below:
Are these new norms?
No, man! They’re not! McLeod and Crowe’s norms data wasn’t new OR different from what’s been published for the last several decades. Instead, this article is basically a summary of previous developmental norms studies. Think about it like the authors grouped previous data together, and combined it all so you could view an average across studies. First, they asked—at what age do 90% of children produce the sound correctly? They grabbed that data from our field's best studies, and averaged it. The infographics represent the average age, across studies, at which 90% of kids produce the sound correctly (or 90% of productions are correct; see article for details). Cool? It may look weird because it's displayed with categories instead of bar graphs or some other version you've been used to seeing. But, frankly, if you’re going to use any study at all for age of acquisition, it should be this one! Because it's aggregated data.
Why are these norms so shocking to everyone?
Well, first you have to ask the question, “What norms are SLPs using now? And how are they interpreting them?”
Google “Speech Sound Development Chart” or “Speech Norms”. See the massive range of what SLPs have been looking at? See how different they look at face value?
And that’s the part of the problem, here: often times, SLPs will look at a norms chart and interpret the ages to mean “age at which a kid should qualify for therapy”. Don't do that! All the norms charts look a little different because they’re based on different studies with different methods of interpreting and displaying the data. Some show bar graphs with the range of mastery, from 50% to 90%. Some charts show the average age of mastery instead. Sometimes "mastery" is defined differently. Some charts collapse across word positions. Or clusters. Or isolated words vs conversation. The list goes on, and on, and on…
But, basically, the point is this: When you look across multiple reliable sources for age of consonant acquisition and mastery, they’re not very different at all. Sources like this and this align well with these “new” (not new!) norms charts.
Guys, the details matter. Other bloggers and scientists have talked about this before. You can’t read all these charts the same way! And when you are reading the charts, make sure you're interpreting them correctly! And, whatever you do, do not interpret bars like this to mean that it’s “normal” to not acquire the sounds until age 8. That’s not what that says. Students qualify for therapy well before the tail-end of that bar graph.
(Further, qualification decisions just can’t be based on norms charts alone because too many other factors are at play (e.g. patterns of errors). For a deeper explanation on qualification and speech sound disorders, see #week31 in the Clinical Research for SLPs Facebook group).
Are these norms accurate?
Yes. I know that's not necessarily what you wanted to hear. But, yes.
So what does that mean for my caseload? What am I supposed to do?!
Yeah. That’s the yucky part, right!?
Because the chart itself isn’t really the point, is it? It’s not that the majority of SLPs don’t know how to read these charts. I think the majority of SLPs do know how to read these charts just fine. The problem is that they’re concerned with the general take-home message, and that is:
Nearly all speech sounds are typically acquired by age 6; many by age 4.
And when we start thinking about what this means for our caseloads, it basically means that we should have a LOT more kids in speech therapy in the late preschool and kindergarten years. It means that waiting to treat things like “r” until after 1st grade isn’t well-aligned with the evidence on when speech sounds are mastered.
And that stinks. Because we want to be doing what’s best for these kids. But we're facing barriers (workload, caseload, silly rules our SPED administrators put in place...). So this chart doesn’t feel good to SLPs, at all. This makes us feel:
And that’s the part that non-SLPs just couldn’t see. That's the part that "broke" the SLP internet.
But I can still use a “wait and see” approach for speech sound disorders, right?
Well, I mean. <sigh> Look, here’s the thing:
To-date, many of us have used a “wait and see” approach with speech sound disorders. That’s how we keep our caseloads under control, right? And, of course, those silly scientists who say that “r” should be treated in kindergarten are completely out of touch with reality, right? Right?! Eh—maybe a little. Maybe a little in that it’s easy for them to forget the workload barriers SLPs face. So when publications “come at you” with statements advocating SLPs do something—like getting these kids in speech therapy sooner—it can be annoying because we feel like we have little control over the issue. And then suddenly we have a workload discussion on our hands, and who do we turn to for help with that? (For real: for those of you wanting to help SLPs, we could really use a “Workload Fairy”. Somebody start that business!)
Because, seriously. Nobody’s treating “r” in Kindergarten without first making massive changes to how SLPs work in the schools. (And in the meantime, the private practice SLPs just take these kids. From parents who are able to pay. Which—thank goodness for the private practice SLPs—but what we’re looking for here is speech therapy even for families who CAN’T afford to send their child outside of school.)
And that’s why this issue is really frustrating for school-based SLPs! Because we feel like we have zero power to fix it, and we’ve been treating speech sound disorders with a “wait and see” approach for so long that the concept of treating early just feels really foreign.
So, Meredith—how do you feel about the fact that neither your team nor any of the scientists involved in the early interpretation and dissemination of this study accurately predicted how SLPs would feel about it?
Now, for me, personally, this is the part that’s most fascinating. And disappointing. And sad, frustrating, etc.
First, my team is usually really good about interpreting research exactly the way an SLP would. Not picking out the parts that scientists care about, but picking out the parts that SLPs care about. But none of us caught that when we read this study. Probably because these aren’t new speech sound norms, and showing “new speech sound norms” wasn’t the point of the study, at all. So it just didn't cross our minds. (See quote block in first paragraph for what the "point" of the study was, or read here.)
But! That doesn't matter. What matters is how and if it impacts clinical practice. So I am disappointed that we didn’t catch this immediately with our review.
But watching how this all played out needs to be a lesson for all of us. Things I learned:
So what now?
At this point, I think the next step that matters most is understanding what questions still linger in SLPs’ minds, and using our science to address those. I would predict it’d be things like:
Insert some comments, below, about what questions or concerns you have! Because, frankly, our science doesn’t matter much if it can’t be implemented. And successful implementation is where our focus needs to be now.
[Updated 1/24/2019] I was chatting with Marie Ireland, and she reminded me of something else that should be said as we're on this topic! Don’t forget that your place of employment may impact how you use information like this in the assessment process. In the U.S., for example:
Thus, a school-based SLP can’t use these norms alone to make eligibility decisions. Here’s what Marie had to say:
"When words like caseload and schools are used, we all need to remember that eligibility for special education—including speech services—has specific steps that have to be considered.
Another addendum... because we just can't stop.
[Updated 2/27/2019] Two of my favorite colleagues, Sarah Bevier and Lisa Kathman from SLPToolkit, have a podcast called "True Confessions". Sarah and Lisa bring such clarity to the realities of being a school-based SLP, and incorporating evidence-based practices into that environment. With invited guest Dr. Kelly Farquharson, a top expert in speech sound disorders, the result was a wonderful episode, titled "We've been interpreting the articulation norms all wrong."
Dr. Tiffany Hogan, of "See Hear Speak" podcast also has a fantastic episode on this topic! See episode #3, "Speech norms, eligibility for speech treatment, and advocacy".
And finally, four new journal articles on speech sound disorders and qualification decisions were published this week as well! The clinical tips contained within are fantastic:
Between this blog, the podcast, and these four journal articles, you'll be set with understanding this topic!
Written by Meredith Harold, PhD, CCC-SLP