Banter Speech & Language
Sydney speech pathologists helping adults and children speak for themselves.
Happy Speech Pathology Week everyone!
This year, the theme is ‘Communicating with Confidence’. Here’s our take:
Principal Speech Pathologist, Banter Speech & Language
Our talented team of certified practising speech pathologists provide unhurried, personalised and evidence-based speech pathology care to children and adults in the Inner West of Sydney and beyond, both in our clinic and via telehealth.
For more than seven years we’ve been writing about evidence-based speech pathology assessments and treatments for children and adults. Our website has had more than 1.3 million views, and we hope we’ve helped share useful information with families and adults who are considering speech therapy.
Whenever two clients ask us the same question, we write an article about it. But, sometimes, a gap opens between what we might think people want to know, and what people actually want to know. Sometimes, clients, readers and followers may not want to ask us a question directly because it might be, well, difficult or even embarrassing.
By looking at the questions people actually use when searching for us, we’ve come to the conclusion that we need to work harder to figure out what people want. So, in this article, we try to answer our readers’ 17 most frequently asked questions about speech pathology. (For context, we include real world examples of what people searched to get to us.)
Why 17 questions and not, say, 10 or 20? Well 17 is as many as we could answer this weekend! (We may keep adding to this article when we get more time.)
Why these questions and not others? These are simply the most common things people ask about. They are not necessarily the things I thought people would want to know, which is of course the point of this article.
Disclaimer: Obviously, our answers are ours, based on our experiences managing a speech pathology clinic and working with children and adults in Sydney, Australia, and by telehealth. We do not pretend to speak for the whole profession in all settings, globally: others will no doubt have different views on some of these questions.
Yes.
An easy one to start with!
Speech pathologists and speech therapists are the same people. Speech pathology and speech therapy are the same thing. I use both terms to describe what I do. I use the terms speech therapy and speech pathology interchangeably because. They. Mean. The. Same. Thing!
Searches: Speech pathology vs speech therapy. Speech pathologist vs speech therapist. Speech therapy vs speech pathology. Speech pathology and therapy. Speech pathology or communication disorders. Speech pathologist v therapist. Speech pathology or therapy? Speech pathology v therapy.
We are professionals who are university-trained to help people with communication challenges, including speech and language difficulties. We work with children and adults; from babies to senior citizens. For example, in our clinic, we work with late talkers, preschoolers, school-aged children, teenagers, young professionals, middle-aged adults, and seniors with communication issues.
Not all speech therapists work with everyone. At Banter Speech & Language, we work with adults and children from many walks of life, including:
Many speech pathologists – not us – work with people with feeding and swallowing difficulties and disorders. We do not practice in this area. (We refer people with swallowing disorders on to speech pathologists who do that work every day.)
Searches: What speech pathologist do? What’s speech pathology? What is speech pathologist? What speech therapy do? Speech pathology meaning.
For children, here are some rules of thumb.
In general, we suggest you speak with a speech pathologist:
Searches: When speech pathology needed? Speech therapy where to start? Why speech pathology is important. Why speech pathology?
Here’s our overview of how speech pathology for children works.
Here’s our overview of how language therapy for children works.
Here are two overviews for how reading and dyslexia interventions work:
Here’s our overview of speech pathology treatments for adults who stutter.
Here’s our overview of speech pathology for preschoolers who stutter.
Here’s our overview of speech pathology for school-aged children who stutter.
Here’s our overview of how principles of motor speech and neuroplasticity can help adults improve their speech.
Here’s our overview of how speech pathology can help people with Parkinson’s Disease.
Many (not all) speech pathology treatments are based on behaviourist scientific principles. You can real more about these principles here.
Most of our articles focus on why speech pathology works, so look around our website if none of the articles above answer your question.
Searches: How speech pathology work. How speech therapy works. What works speech therapy? Speech therapy interventions. Speech therapy help. Speech therapy techniques. Speech therapy tools. Speech pathologist assessment.
Yes.
This is a very – VERY – common question from our readers.
Here’s what we want parents of late talkers to know.
Here’s our overview of how we assess toddlers.
Here are some principles we use to help families:
Searches: Will speech pathology help my toddler? What’s speech therapy for toddlers? Will speech therapy help my child talk? Speech therapy for toddlers at home. Speech therapy 2 year old. Speech therapy for toddlers. Speech therapy for 2 year old. What is speech pathology like for toddlers? Speech therapy books for toddlers. Speech therapy toys for 2 year olds. Speech therapy words. Will speech pathology help my child talk? Speech pathology with toddlers. When speech pathology for toddler?
Yes.
Here is some information about how and when preschoolers typically learn their speech sounds.
Here is some information about preschoolers’ speech sound error patterns (and when they should disappear).
Here’s how unclear speech can affect later reading outcomes.
Here’s our overview of why speech and language are so important for school readiness:
Here an overview of three evidence-based treatments we use to treat speech sound issues:
Here are overviews of some common language targets for preschoolers, including:
Here’s an overview of the Lidcombe Program for preschoolers who stutter.
Searches: Speech therapy for 3 year old. Speech therapy for kids. Speech therapy for child. Speech therapy exercises for a 3 year old at home. Will speech pathology help my 3 year old.
Yes.
But we are not teachers or tutors, as we explain here.
Here are some overviews of speech therapy interventions for common issues including:
We’ve also written about common related issues like working memory, auditory processing disorder, ADHD, sleep disorders and social and emotional issues.
We’ve also published tips for teachers and others working with students with language, reading and learning disorders, social skills and Do-It-Yourself evidence-based study techniques.
Some children have residual speech sound issues, which cause ongoing social and employment issues. We’ve written about it here.
Searches: Will speech pathology help? Will speech pathology help my child? Speech pathologist schools. Speech pathologist and academic. Speech pathologist and vocabulary. Higher level language.
Yes.
We’ve written a free book for parents about this.
Since then, we’ve added more information:
Searches: Speech therapy for dyslexia. Speech therapy reading difficulties.
Yes.
For our overview of lisps, including an explanation of different types of lisp, see our FAQs.
For our home program for children who have interdental lisps, see our Pesky Lisp Fixer.
For our home program for children who have lateral lisps, see our Slushy /s/ Zapper.
For adults who lisp, see our Lisp Fixer online course.
Searches: Can speech therapy get rid of a lisp? Speech therapy lisp. Speech therapy s sound. Can speech pathologist fix a lisp?
Yes.
For an overview of speech sound treatments, see here.
For information about when children should be able to say each sound, see here.
For information about common error patterns like leaving out sounds and ‘gliding’ of /r/, /l/ and ‘y’ (/j/) sounds (and when they should be gone), see here.
For a home program for trouble with the /r/ and/or /w/ sounds, see our /r/ Remedy.
Searches: Speech therapy can’t say r. Speech therapy r sound. Speech therapy r sounds like w. Speech therapy k sound. Speech therapy letter l. Speech therapy y sound.
Yes.
The first step is to find out what is contributing to it – is it caused by difficulties with speech sounds or a language problem (or both), or something else? Are other things, like hearing difficulties, middle ear infections, or tonsil and adenoid problems contributing? A speech pathologist can help you get to the bottom of what’s going on and treat speech sound issues.
Behavioural speech therapy may be an option when there are no speech sound or physical issues contributing to the mumbling. For children with no speech sound issues, we have a simple home program – Mumble Buster.
Searches: Speech therapy to stop mumbling. How to stop mumbling.
Yes.
Stuttering and stammering mean the same thing. You can read more here.
Many young children recover from stuttering, although recovery means different things to different people.
If you have a child who is stuttering, should you wait and see what happens? No. Here’s why.
There is – as yet – no cure for stuttering. But there are several treatments available to help people manage stuttering and its effects.
Searches: Can speech therapy cure stuttering? Can speech therapy help with stuttering? Speech therapy to stop stuttering. Can speech pathologist cure stuttering?
Yes.
Accent modification is controversial and often unnecessary. There is no one right way to speak English (or any other language). English is a global language, and we should celebrate local differences, like Singlish or Indian English, rather than criticise them.
Sometimes, accents get in the way of being understood. Sometimes, they can get in the way of important life goals like getting a job or a promotion. For most adults, ‘getting rid of an accent’ is not realistic. But there are evidence-based principles of clear speech that can help increase your intelligibility and comprehensibility while staying true to yourself and your heritage.
Here’s our overview of how speech therapy can help people to modify their accents.
Here are things you can do to increase your intelligibility.
Here’s why some people choose to modify their accents.
Search: Speech therapy to lose accent.
Yes.
The great thing with technological advances in recent years is that we can provide speech therapy anywhere. We have lots of rural and international clients, including in remote areas without another service.
We can use Zoom, Skype, Coviu, or Google Meet or Hangouts to help children and adults in their homes by telehealth. Speech pathology is nearby anyone with an Internet connection!
We’ve been doing stuttering therapy by telehealth for years.
We also make home programs and online courses for people who want to do speech therapy in their home. A good example of this is our self-paced preschool language readiness course.
Searches: Speech therapy nearby. Speech therapy with Google Meet. Speech therapy with Zoom. Speech therapy with Skype. Speech therapy with Coviu. Speech therapy via Zoom. Speech therapy via Skype. Speech therapy to do at home. Speech therapy with distance learning. Speech therapy online. Speech therapy online courses. Speech therapy telehealth. Can speech pathologists travel? Speech pathology to do at home? Speech pathology telehealth.
No.
You can call and have a chat with us any time Monday-Saturday. If you decide to book in, you do not need a referral and can get started straight away.
For people with reading difficulties, you do not need to wait for a formal diagnosis of dyslexia to get started. Evidence-based treatment for reading difficulties is the same for people with and without a formal diagnosis of dyslexia, and the earlier you get started, the better.
To get in touch with us, go here.
Searches: Do you need referral for speech pathologist? Speech pathology without IEP.
This depends on your circumstances, but usually, in Australia, yes. You can read more about rebates and insurance here.
Searches: Speech pathology Medicare. Speech pathology private health insurance.
Here. We love to share our knowledge and to make practical resources to help people.
We’ve seen a surge of interest in our therapy resources recently, both from families and other speech pathologists. Our library of resources continues to grow.
By way of overview, we have published:
And we’re just getting started!
Searches: Speech therapy activities. Speech pathology facts. Speech therapy books. Speech pathology blog. Speech therapy books for parents. Speech therapy tips for parents. Speech therapy exercises for 3 year olds at home. Speech therapy games. Speech therapy game apps. Speech therapy home exercises. Speech therapy materials. Speech therapy materials pdf. Speech therapy online free. Speech therapy pictures. Speech therapy questions. Speech therapy resources. Speech therapy resources for parents. Speech therapy sentences. Speech therapy toys. Speech therapy videos. Speech therapy worksheets. Speech therapy websites. Speech therapy webinars. Speech therapy YouTube. Speech therapy you can do at home. Speech therapy courses. Speech pathology images.
Yes. Here are our four favourites, with our answers in brackets:
With this website, we set out to make speech pathology less mysterious and more transparent. This whole enterprise exists to share quality information with you about speech pathology and to answer your questions. We welcome any questions you may have about speech pathology, speech therapists or communication disorders – even tricky and confronting ones.
Readers and followers: You can ask us anything!
Principal Speech Pathologist, Banter Speech & Language
Our talented team of certified practising speech pathologists provide unhurried, personalised and evidence-based speech pathology care to children and adults in the Inner West of Sydney and beyond, both in our clinic and via telehealth.
Every year, we try to improve our practice. This year, we looked at the effectiveness of our language therapy for children with developmental language disorders. We looked at the research, talked to some clients, and reviewed our clinical data to see if we could identify some key ingredients of effective language therapy.
Having done this work, we thought we’d share our key findings:
Communication is based on joint attention. Children learn more when their attention is directed at the thing you are trying to teach them (e.g Eriskon, 2008). Therapy that gets and holds a child’s attention is more effective than therapy that doesn’t (e.g. Gillam & Loeb, 2010).
Many people think that intense therapy is better than less intense therapy (e.g. Gillam & Loeb). But more isn’t always better (e.g. Kamhi 2014): increasing the frequency of language therapy does not always improve outcomes (e.g. Ukrainetz et al., 2009; Fey et al., 2013).
Children do better with:
Learning plateaus and threshold effects exist for both language and literacy (e.g. Ambridge et al., 2006; Riches et al., 2005). There may be points of ‘diminishing returns’, where little additional benefit is derived from more language therapy (e.g. McGinty et al., 2011). You can read more about language therapy ‘dosage’ here.
The evolution of human communication is founded on interactions between people cooperating for a common purpose (Tomasello, 2017). This means most people are ‘biologically primed’ to learn to be self-aware and aware of others, to process facial expressions, to have joint attention, and to take-turns in interactions with others.
Some children need help to develop these skills. That’s one reason interactive learning is better than learning passively; and why naturally interactive activities like shared reading is such a useful language learning technique with young preschoolers.
To improve communication skills, children need feedback on their attempts. Feedback can be verbal or non-verbal or both. Feedback should be specific to the goal (not general platitudes, like ‘good talking’). Too much feedback (positive or negative) can be counterproductive:
Too much negative feedback can be demoralising. In early language therapy, recasting is more productive than correction.
We’re ambivalent about the use of external rewards in therapy. But there is no denying that the day-to-day practice of language therapy is heavily indebted to behaviourist learning principles.
Most therapists recognise the importance of internal motivation and the benefits of rewards in learning. In practice, external rewards like stickers and tokens can help some children do better in therapy, e.g. by increasing their attention and motivation to do the work, to help them increase their awareness of feedback on their performance and to reinforce new learning.
We should target different kinds of language problems within each session. For example, in my 45-minute language sessions with preschoolers and school-aged children, I aim to target at least 4 different language goals, including to treat language content, form and use difficulties.
We’ve known for a while that mixing activities can improve motor learning in some conditions (e.g. Wulf & Shea, 2002). There’s growing evidence that ‘interleaved’ practice or ‘interleaving’ also works on cognitive tasks. Mixed practice may promote general language development because it allows children to compare different kinds of problems more readily, and to make more connection. It’s also possible that mixed practice creates distributed learning conditions, which help students retain information and learn more effectively. You can read more about some of this research here.
Short bursts of treatment on a goal spread over weeks may help children to learn new skills better than intensive treatments squeezed into one session or taught over consecutive days (e.g. Riches et al., 2005; Smith-Locke et al., 2013). This is called the ‘spacing effect’ and has been studied extensively in the context of improving study skills.
Another way of saying much the same thing is to say that distributed practice – having intervals between targeting the goal – is more effective than massed learning (e.g. Baddely, 1997). Over 100 years of research and over 300 studies show the benefits of distributed learning across a variety of different cognitive domains (Bruce & Bahrick, 1992).
Taken together, the research suggests that spaced practice exploits a fundamental human learning mechanism that boosts both initial performance and retention (Bahrick & Phelps, 1987; Kamhi, 2014). There is good evidence that spacing and distribution of teaching episodes is particularly useful for children with language learning difficulties and may be even more important than treatment intensity and dose (e.g. Riches et al., 2005; Yoder et al., 2012).
These require the child to recall something they have learned previously and to re-produce the information.
Sometimes, in therapy, children can spend too long simply re-reading, imitating or listening to language from set materials. But retrieving information from memory facilitates long-term retention (e.g. Bjork, 2011). This may be one reason why spelling and writing benefit reading (e.g. Graham & Herbert, 2010). It may also explain why doing practice tests (for academic tasks), making your own learning materials (rather than just using someone else’s materials), and handwriting your own notes, are useful ways to learn and remember things. You can read more about retrieval practice here.
Most children are naturally inquisitive – asking their parents and others lots of ‘why’ questions. Some children are good at explaining ideas to themselves.
Some children need help to learn to ask ‘why’ questions when listening to language or reading. Others need to learn to explain things to themselves to check for comprehension. These skills – ‘elaborative interrogation’ and self-explanation – can be taught and learned. You can read more about them here.
From an evolutionary perspective, humans are primed to pay attention to the biological and physical world around us. But some clients with developmental language and other developmental disorders need help to develop basic primary knowledge about their physical environment, including basic category and sequencing skills.
It’s also important for children to learn about their specific cultures, world and universe. Having a vast store of quickly available, previously acquired knowledge enables the mind to take in new information in less time and with less effort and to link it to existing knowledge (Hirsch, 2003). Helping children to know more about the world they live in: speeds up basic comprehension and leaves working memory free to make connections between new and previously learned information; helps children to make sense of word combinations that have ambiguous meanings, helps with inferencing and helps older students to understand metaphor, idiom, irony, and other higher level language uses.
You can read more about the importance of background information here.
Play is often discounted, even denigrated. ‘I’m not paying you to play games with my child.’
But play serves an important biological purpose: Through no-stakes, imaginary world practice, kids learn vital life skills through self-directed play, including many language and social skills essential for life success. Peer development and cooperation skills are often acquired through play; and social skills can often be improved more meaningfully through planned peer-peer practice in play, rather than adult-child interactions, which often look very different (e.g. Cordier et al., 2013).
Language is complex. For children with language and learning disorders, improvements can be slow and therapy can be hard-going. It’s understandable that families (and some speech pathologists) are drawn to well-marketed programs that promise quick fixes. Intuitively, we can understand why some people think that working on sub-skills – like auditory processing or working memory – might result in improvements to language skills.
But, unfortunately, the research to date tells us that it doesn’t.
Instead of working on sub-skills and processes in isolation, we should spend our limited therapy time on functional activities that help children to comprehend and use language – even though it is often hard work.
Developmental norms and language assessment results are important. But it’s more important to understand the family’s key concerns – the things they want you to work on right now – especially if it is affecting relationships.
For example, if a parent gets really stressed and annoyed when their child leaves out her articles or makes errors with a particular irregular plural like ‘mice’, this is a legitimate goal, even if, developmentally, it isn’t next in sequence or (from the speech pathologist’s perspective) particularly unusual at the age.
Similarly, if the child gets really frustrated about his inability to explain cause and effect relationships in words, and lashes out at people who don’t understand him, then working on ‘because’ and ‘so’ at the sentence level is a better goal than a few pronoun errors that don’t affect his ability to be understood.
I’ve worked with a teenager whose only goal was to write effective social media posts. I’ve worked with adults who are sick of mis-ordering their lunches. I’ve worked with people with lifelong language issues who simply wanted to tell their story to others in an effective way. All three were important and meaningful goals. But you won’t find any of them on a developmental management chart.
Let’s look at some examples:
Over the last 60 years, we’ve amassed lots of information about typical language development (e.g. Nippold. 2014). But not all goals are of equal importance when working with children with developmental language disorders. Knowing what to treat and when is essential.
For example, when working on syntax, too many of us work on early developing targets, like ‘-ing’, <in> and <on>, even though there is little evidence that children with language disorders have long term problems with these targets. Many speech pathologists are still trained in outmoded mental models like Brown’s so-called 14 morphemes, and operate under the mistaken assumption that these need to be mastered before you can move on to more advanced topics. It’s total nonsense.
With limited time, we need to be more ambitious and judicious in selecting goals. For example, we should target:
Oral language skills (talking and understanding) and reading skills are linked; oral language and reading skills are mutually beneficial. Improvements in spoken language skills improve reading skills, and vice versa. Oral language and reading skills piggy back on each other during the school years (Snow, 2016). If one is impaired or delayed, the other suffers. For example:
This seems obvious, but is sometimes forgotten. Children get enough homework without having language therapy home exercises piled on top. For older children, in particular, language goals should often be pursued while working on school homework and assignments. For example:
To enhance learning, we need to vary both the complexity and the conditions of practice (Bjork, 2011). This may be as simple as practicing the skill in different places with different people (one of the key advantages of home practice).
Working on language in a variety of contexts is important (e.g. Gillam et al., 2012). This is especially true for higher level language targets, e.g. idioms and metaphors. In many of our oral language therapy resources for school aged children, for example, we include a variety of exercises including listening to stories, interpreting idioms, answering questions, comparing and contrasting objects and characters, discussing and defining academic vocabulary, justifying opinions, drawing inferences from information given, divergent thinking, cultural knowledge about the world, language from myths and legends, morphological awareness and story generation with semantic constraints. We also work on complex sentences used in verbal reasoning tasks. You can see examples of this type of approach in our Listen, then Speak resources, Level Up Language course and Exam Verbs library.
If a child needs help in one particular context, e.g. ordering food at a school canteen, the best place to work on that goal may be the canteen. In situations like these, scripts and video modelling to pre-practice the task can be helpful.
Language therapy is a team sport. Ideally, it involves the child, the speech pathologist, the child’s parents or carers, educators, general practitioners and other medical and allied health professionals all pulling in the same direction – and in the best interests of the child.
Things can get complicated when school starts. The speech pathologist should coordinate with learning teams to work out how best to support the child and the school. Speech pathologists can help with evidence-based suggestions to help children with language cope with the curriculum and teacher training on things like risk factors for developmental language disorders and symptoms to look out for.
Speech pathologists need to listen carefully to teachers, to understand the effects of the child’s language issues on how the child is participating at school. They also need to share information about the sometimes long term social effects of developmental language disorders; and the heightened risks of behavioural and emotional issues.
Teachers can help by spotting children with language difficulties early and be referring them for assessment. Depending on assessment results, teachers, learning support teams, speech pathologists and parents can work out how best to support the child. Sometimes, this means ‘dividing’ up supports, for example, the speech pathologist focuses on oral language comprehension, and the school focuses on reading and writing supports. Often, in practice, it’s more complicated than that for the simple reason that language and literacy are so interconnected. Things can get even more complicated when the child has some behavioural, attention or mental health issues, and/or if the child has additional diagnoses, like ADHD, that also often affect language development.
There are lots of different language therapy techniques, and a full review is beyond the scope of this (already very long) article. Some are speech-pathologist-directed; while others are more child-centred. Our therapy tends to mix both approaches, depending on the child and their needs.
For younger children, many speech pathologists use implicit approaches, like imitation, modelling and recasting. For older children, therapy tends to take a more explicit or direct approach. I think we owe it to all clients – even preschoolers – to explain what we are working on and how.
Many techniques share a few common elements:
For older children, direct instruction in context can be more efficient.
Interestingly, many of these ideas and approaches share features with Direct Instruction teaching of secondary knowledge, perhaps reflecting the fact that for many older children with language disorders, language targets need to be explicitly taught, rather than picked from exposure or through statistical learning.
Direct Instruction is teacher directed, explicit and carefully sequenced, with a focus on learning. Often, instruction starts with a teacher model, then practice together, and finally by independent practice – the so-called ‘I do, we do, you do’ method of teaching. Spaced distribution, interleaving and retrieval practice can be built into this form of teaching.
As Fey noted way back in 1988, language is way too complex for us to ‘teach’ every form and use to children with language disorders. Language serves too many functions, expresses too many meanings, and can be looked at in too many ways. An infinite number of word and syntax options exist, and language is always evolving. We have to focus on how best to support the child in front of us.
In this article, we’ve highlighted several elements that we think can be used to improve language therapy outcomes for children with language disorders. We’re sure there are many factors we didn’t cover, and there are no doubt many factors that have yet to be discovered. But we’re hopeful this work gives us a framework to keep getting better at language therapy. The plan is now to put all this knowledge into practice; and to make sure we’re providing the best service we can to all of our language therapy clients.
Principal references:
Kamhi, A. (2014). Improving Clinical Practices for Children with Language and Learning Disorders. Language, Speech, and Hearing in Schools, 45, 92-103. Gillam, R.B.,
Loeb, D.F. (2010). Principles for School-Age Language Intervention: Insights from a Randomised Control Trial, ASHA Leader; January, pages 10-13.
Ebbels, S. (2014). Effectiveness of intervention for grammar in school-aged children with primary language impairments: A review of the evidence, Child Language Teaching and Therapy, 30(1), 7-40.
More reading on explicit and direct instruction and evidence-based learning practices:
Related articles:
Principal Speech Pathologist, Banter Speech & Language
Our talented team of certified practising speech pathologists provide unhurried, personalised and evidence-based speech pathology care to children and adults in the Inner West of Sydney and beyond, both in our clinic and via telehealth.
We’ve been asking ourselves an important question recently: What, exactly, does ‘recovery’ from stuttering mean?
We work with toddlers, preschoolers, primary school-aged children, teenagers, and adults who stutter. We work with clients with mild stuttering; and others with severe stuttering. We work with clients who stutter consistently with all people in all situations, others who stutter only in some situations (e.g. when reading, or talking on the phone, or during presentations), and yet others who stutter only occasionally (e.g. when tired, angry or nervous).
We listen to our clients, read the peer-reviewed research, and reflect on our clinical data. And we still struggle to answer the most basic of questions:
When can we say a client has recovered from stuttering?
Fortunately, a group of researchers has been looking at this question recently in the context of early stuttering (Einarsdóttir et al., 2020 – see below for full citation).
Before we get to their interesting findings, let’s revisit some of what the evidence tells us (and doesn’t tell us) about stuttering and recovery:
Stuttering usually starts in early childhood. Most children recover. But a sizeable minority don’t.
For children (and teenagers and adults) who do not recover in the preschool years, stuttering can be persistent – even with good, evidence-based treatment and improvements in fluency. To date, there is no cure for persistent stuttering (although there are some very smart people working hard on it). Treatment goals often involve learning coping strategies to manage stuttering and its effects.
Can we predict who will recover and who won’t? Some researchers have identified a few factors that seem to increase the chance of recovery, including being a girl. More recent research suggests that children who start to stutter at earlier ages are more likely to recover; and that children who have been stuttering for less than 18 months are more likely to recover than those who stutter for longer than 18 months. Children who receive treatment within 15 months of stuttering onset are more likely to recover than those who receive treatment later. Children with advanced speech, language and literacy skills may be more likely to recover than those with delayed or disordered speech or language (e.g. Einarsdóttir et al., 2020.)
In truth, we don’t know whether a particular child will recover. This is why we recommend early treatment for all young children who stutter.
As we’ll discuss below, recovery rates depend a great deal on your definition of ‘recovery’. But there are a few other factors that probably inflate some of the published findings:
If we only look at people who finish treatments, we may think we are more successful in treating early stuttering than we actually are.
Many (but not all) peer-reviewed studies of children who stutter exclude children with speech-language disorders, attention disorders, Autism Spectrum Disorders, and intellectual disabilities. Many of my clients who stutter have speech and language challenges as well. If advanced speech and language skills are possible predictors of recovery, aren’t we at risk of reporting inflated recovery rates because we are excluding children with delayed or disordered speech?
There are other problems with inclusion criteria used in some studies, too. Many studies, for example, exclude bilingual children. My case load includes many children who are learning more than one language. Are recovery rates different for bilingual children? We don’t know enough about this yet.
Few studies follow people who stutter from preschool to adulthood, middle-age and late ages. Children who complete preschool treatments and are deemed to have ‘recovered’ may relapse or otherwise start stuttering at some later point. We see lots of older clients who report they were treated successfully as preschoolers.
Low levels of stuttering can be hard to distinguish from the speech of people who do not stutter. If a client stutters so mildly that no one can tell, are they ‘recovered’? If not, why not?
Many people who stutter find effective ways to self-manage their symptoms. For example, some of my clients:
Adults who stutter are at a greater risk of developing social anxiety and other mental health issues. But many people who stutter do not have social anxiety or other problems and lead very full, healthy lives. Do we count clients who stutter but mask their stuttering symptoms and participate in life effectively ‘recovered’? If not, why not?
Is the goal of therapy to get rid of the stuttering – to ‘fix the impairment’ – or to help clients manage the effects stuttering on their participation and mental health and maximise quality of life outcomes? Do we measure recovery differently depending on the goal?
For preschoolers who stutter, there are very good, evidence-based treatments, including the Lidcombe Program and the Westmead Program. The stated aim of these programs is to eliminate stuttering.
Once a child starts school, stuttering gets much harder to treat and is rarely eliminated altogether. The treatment focus switches away from the elimination of stuttering to helping children self-manage their stuttering in situations that matter most to them, like talking in class and in the playground, giving speeches, performing in school plays or in sports.
For teenagers and adults, speech restructuring or prolonged speech treatments, like the Camperdown Program have the highest level of evidence. But, again, they don’t work for everyone. For example, in some situations, some clients would rather stutter than use speech restructuring techniques.
Over the years, we’ve observed that stuttering affects people in very different ways. For some clients, it is a really big deal that has a profound, negative effect on their mental health, social participation, and school or work goals. For other clients, stuttering seems to have little obvious effect on their lives.
Stuttering severity alone is not always the main issue. Some people seem to be fairly untroubled by even quite severe stuttering. For others, very mild stuttering can have a big, negative effect on their quality of life and health.
Is recovery determined by the reduction of stuttering severity or symptoms, by the quality of the client’s life despite the effects of stuttering, or a combination of factors?
The answer must be different for different clients.
In a recent study, Einarsdóttir and her colleagues reviewed 23 longitudinal studies to examine the persistence and/or recovery rates in children who stutter. They found a mean recovery rate of 58.7% across studies. But they also found reported recovery rates ranging from 6.3% to 94%!
One reason for this startling inconsistency across studies is that different stuttering researchers defined ‘recovery’ very differently. Some:
In defining recovery, some researchers used stringent measures – e.g. requiring no stuttering whatsoever measured by experienced clinicians across multiple speech tasks. Others allowed some stuttering (e.g. less than 3% of syllables stuttered, or severity ratings of 2 or less on a rating scale of 0-7). Others used purely subjective measures like family reports, or didn’t specify their definition of recovery at all. Far too few studies asked the child to report whether they felt like they had recovered.
All this inconsistency makes it very difficult to give families good information about the ‘true’ recovery rate or even what recovery might look like. To help improve the evidence-base, Einarsdóttir and her colleagues studied 38 monolingual children who stuttered, measuring stuttering on two occasions: (1) when they were aged 2-5 years; and (2) seven years later, when they were 9-13 years of age. They applied four different criteria for the definition of ‘recovery’, based on previous research:
(A) A child has a stuttering frequency of less than 3% syllables stuttered in video recorded speech samples.
(B) A child meets all four of the following criteria: (i) two speech pathologists and parents agree that the child no longer stutters; (ii) parents had to be able to report when the stuttering stopped and confirmed that the child had not stuttered for the previous 12 months; (iii) stuttering severity was rated as ‘borderline or no stuttering’ by speech pathologists based on the speech sample; and (iv) the average percentage of stuttered syllables was 3% or less.
(C) A child meets all the criteria in (B) + the child self-reported that he was no longer stuttering.
(D) A child meets all the criteria in (C) and no stuttered speech at all was present in the speech sample.
They found that all children became more fluent with age. But the recovery rate varied greatly depending on the criteria used. If:
So the rate of recovery ranged from 13.2%-94.7%, depending on the criteria applied – broadly consistent with the results of their analysis of previous longitudinal studies. The most common criteria applied in previous research is (B). But, interestingly, by including children’s self-reports on whether they felt they had recovered (Criteria C), far more children were classified as not-recovered.
A few caveats to this study: It was fairly small – 38 children (28 male, 10 female). All participants lived in Iceland. The study excluded bilingual children and children where ‘there was evidence of severe language impairment’ or signs of ‘neurological disorder’. The first author was not blinded to which clients identified as recovered. Selection bias may have affected recruitment. The children were only assessed at two points, and in clinical contexts (mitigated by obtaining multiple speech samples on different tasks). Importantly, some children were treated during the study term; and others were not, so no conclusion could be made on whether treatment may have affected outcomes.
When we talk about ‘recovery’ from stuttering, we need to be clear on exactly what we mean; clear about what the evidence tells us about recovery rates for early and persistent stuttering (including what we don’t know, and some of the limitations of the published studies); and clear about the goals of stuttering therapy.
Recovery means different things to different people – including to different people who stutter. For many clients, requiring completely fluent speech as a criteria for recovery is unrealistic and potentially demotivating and demoralising. Ultimately, the most important view is the client’s, recognising that there is as yet no cure for persistent stuttering.
Related articles:
Principal source: Einarsdóttir, J.T, Crowe, K., Kristinsson, S.H., & Másdóttir, T. (2020). The recovery rate of early stuttering. Journal of Fluency Disorders, 64, 105764.
Principal Speech Pathologist, Banter Speech & Language
Our talented team of certified practising speech pathologists provide unhurried, personalised and evidence-based speech pathology care to children and adults in the Inner West of Sydney and beyond, both in our clinic and via telehealth.
We work with many children who have unclear speech. For some families, speech therapy can be mysterious, confusing, tedious, or even intimidating. It shouldn’t be any of those things.
In this article, we will explain what we do and why we do it. We’re going to answer some questions we get asked a lot. We’re going to try to avoid (or at least explain) jargon and acronyms that plague the topic. Where possible, we’ll link to some other articles that address some of the points we cover in more depth.
Most children learn to speak without any help. But some experience significant delays in learning to use speech sounds correctly in speech. We call these delays ‘speech sound disorders’.
Learning to speak like an adult takes time; and all young children make at least some speech errors. When should you be concerned?
Unfamiliar adults should be able to understand about 80% of a typically developing 3-year old child’s speech. By four years of age, children should be fully intelligible to unfamiliar adults (Gordon-Brannan & Weiss, 2006).
Here are some rules of thumb. If:
you should touch base with your local speech pathologist for a chat.
About 75% of children with speech sound disorders correct their speech by the age of 6 years. Of the remaining 25%, most resolve by the age of 9 years. A small percentage continue to have residual problems, often with sounds like /r/, /s/ and the ‘th’ sounds (e.g. in ‘thing’, and ‘this’) (Shriberg et al., 1997; Kamhi, 2006).
So why not just wait?
The evidence is clear: children with speech sound disorders are at a higher risk for problems down the track. Systematic reviews have shown that children with speech sound disorders are at greater risk than typically developing children when it comes to:
(e.g. McCormack et al. 2009.)
As we explain here, a child’s school readiness is:
As a speech pathologist with a special interest in school-aged language and reading, I am particularly concerned when I meet a child about to start school with unclear speech, difficulty distinguishing speech sounds, and difficulties expressing their thoughts and feelings in sentences.
Yes: this has been proven by systematic reviews of peer-reviewed research evidence (e.g. Law et al., 2004). Similarly, evidence from a comprehensive 2011 narrative review suggests that it is better for children who have phonological impairments to receive intervention than no intervention at all (Baker & McLeod, 2011).
Children have their best chance of fulfilling their potential if they are provided with effective and efficient treatment before starting school (Baker & McLeod, 2011; Beitchman et al., 2001, Nathan et al., 2004). But it is never too late to get help with your speech, and we work with many adults with speech sound issues.
Yes. Some researchers have tried to classify them. For example, the Speech Sound Disorder Classification System looks like this:
(Shriberg et al., 2010).
This classification system is very complicated, and not everyone agrees with it. I like it in concept, but find it hard to apply in practice. Instead, in our clinic, we tend to group speech sound disorders into three broad categories that are not mutually exclusive: language-based, articulation-based, and motor speech-based speech disorders.
Classifying a given client’s speech sound disorder is not always clear cut. Children don’t tend to fit into neat categories. For example:
You have to look at the child in front of you and work out what’s going on with their speech.
Our speech assessments are designed to help us figure out:
To get this information, we:
Depending on the results, we might need to do other tests and assessment tasks, e.g. if we are concerned about whether a client might have childhood apraxia of speech.
This is a question we spend a lot of time asking ourselves. It’s a question we expect to keep asking ourselves as more research is published and as we become better at what we do.
As health professionals, we are committed to evidence based-practice. This means we need to consider and then integrate three things:
It’s hard to find and apply the best research for clinical use. Key challenges include:
Despite these difficulties, it is our job to do our best to translate new research on effective treatments into practice. Examples of evidence-based therapies we have been able to translate or adapt and use in our clinical practice include:
Sometimes, we’ve had to send staff off on expensive post-graduate training courses to learn therapies. But, increasingly, researchers are making their training materials freely available and accessible at any time, which is a huge help for busy clinicians. Two examples are ReST and DTTC – both treatments for childhood apraxia of speech.
When I think about the multitude of phonological interventions, I’m reminded of a funny quote from the (now terribly dated) 1980s English comedy, ‘Allo ‘Allo:
“He was the man of a thousand faces – every one the same.”
With the experience of using several different approaches, common features and patterns emerge: elements that seem to work most of the time, regardless of which therapy approach we take.
Of course, many brighter minds than mine have observed the same thing. Noting that many therapy approaches seem to work, some researchers have questioned the importance of finding ‘the’ best treatment approach, and highlighted instead the importance of identifying the best therapy targets (e.g. Gierut, 2005). In other words, what is treated may be more important than how it is taught (e.g. Kamhi, 2006). But I think it goes further than just targets and approaches: beneath the surface, many therapies share more similarities than differences – especially when they are translated into practice.
What follows are some examples of therapy elements and practices that we have found help our clients to improve their outcomes in speech therapy, regardless of which approach we take. Some are consistent with principles of effective language therapy (e.g. Bayles, 2011; Gillam & Loeb 2010). Others are more consistent with principles of motor learning. Some are principles distilled by researchers thinking about how we move speech pathology practices forward (e.g. Kamhi, 2006; Rvachew, 2017; Baker et al., 2018). Others are just things we have found work for many families.
(a) General elements
(b) In the sessions
(c) Home practice
No speech treatment works for all clients or families in all conditions. At intake, we look at known risk factors, such as family histories of speech difficulties, gender, and hearing issues. During the initial assessment, we evaluate the client’s language skills so that we can explain what we are doing in a way the client can understand. To make treatment recommendations to families after the assessment, we consider the nature and severity of the client’s speech disorder, the child’s age, when the child is going to start school, the success (or failure) of any previous therapy, and the child’s motivation, attention, and interests (Kamhi, 2006).
In therapy, we try to use the child’s current speech strengths and abilities. We need to have a good idea about the amount of support we will need to give the client to stay focused and motivated to work on difficult speech tasks (Shriberg & Kwiatkowski, 1994). For some children, we need to get creative and use the child’s interests to encourage them to do the work. That’s why I know way too much about Pokemon and sharks, Disney Princesses and scorpions, dinosaurs and pirates, Minecraft and Roblox, Batman Lego and semiprecious stones, diesel trains and NBA basketball.
We need to know what the family thinks about the child’s speech and speech therapy. The level of concern a parent has can play an important role in whether the child is assessed, attends therapy, and does the work between sessions (Kamhi, 2006).
We need to answer questions – even when the answer is ‘I don’t know’. Whenever we get asked a question a second time, we try to write an article about it to share with clients. For example, children’s speech development can be affected, at least temporarily, by chronic middle ear infections or other types of conductive hearing loss. Tonsil and adenoid problems can affect speech clarity, as can allergies, colds and other things that leave kids with blocked noses. Sleep disorders can affect language development. Stuttering and cluttering can make speech hard to understand. Rate control issues can reduce intelligibility. Bilingual children are learning two speech sound systems. Braces can cause mild speech distortions for a while; and some older children continue to have residual speech difficulties that have social and work implications. Some people think that tongue ties and sucking a dummy for too long or thumb sucking affect speech development, but I’m not convinced (based on the evidence to date).
For time, logistical or financial reasons, some of our clients can only attend therapy once a fortnight or less frequently. This can be a challenge, e.g. for motor speech treatments that require high treatment dosage.
Some of our clients have other health issues, like hearing problems, attention difficulties or sleep disorders. For some clients, speech isn’t always the family’s highest priority – the client may have other health challenges, or simply be focused on other goals that are important to them, e.g. sport or music. Many of our clients have more than one communication challenge (e.g. speech disorders plus stuttering, language difficulties, social difficulties, voice problems, and/or dyslexia).
We have to consider all these issues and tailor our therapy to each client and family. Again, this is difficult, but it’s our job.
Lots of elements go into providing good speech therapy. Research, clinical experience and information about clients and their goals all need to be integrated to provide evidence-based, quality care.
In this article, we’ve tried to explain what we do in speech therapy and why we do it. We’ve identified some things that we think make a difference in our client’s results to date. But we need to keep reading new research, improving our systems and resources, training ourselves in new techniques, measuring our results, and sharing information with families about new developments to do our job properly. Most importantly, we need to work with families and children with speech sound disorders to make sure they know what we are doing and why, and to do all we can to ensure our therapy works for them.
Principal sources:
As always, any errors of interpretation are mine alone.
Related articles:
Principal Speech Pathologist, Banter Speech & Language
Our talented team of certified practising speech pathologists provide unhurried, personalised and evidence-based speech pathology care to children and adults in the Inner West of Sydney and beyond, both in our clinic and via telehealth.