Understanding the experiences of children with speech sound disorder in speech and language therapy using emotional mapping

The publication of phase 2 of the CATALISE project in 2017 clarified terminology for children with developmental language disorder (DLD) or delay but unintentionally muddied the water for children with unintelligible speech. A diagnostic label of DLD (phonology) indicates poor prognosis and phonological disorder that persists into middle childhood. However, in contrast to other diagnostic labels that fall under the overarching term of speech sound disorder (SSD), DLD (phonology) does not elucidate the characteristics of the child's speech nor does it point us in the direction of appropriate intervention. The aim of this paper is to discuss terminology in SSD leading to an evidence-based model which builds on the model of DLD developed in CATALISE, supports descriptive diagnosis and signposts intervention. Following a focused review of literature proposing or describing terminology for SSD, an expert group of researchers in developmental SSD proposed a revised model of existing terminology. Groups of UK speech and language therapists (SLTs) who provide services for children with SSD were asked to comment on its acceptability and feasibility. A three-level terminology model was developed. This comprised an overarching Level 1 term; Level 2 terms that differentiated SSD of unknown origin from SSD with associated or underlying conditions; and specific diagnostic terms at Level 3 to support further assessment and intervention decisions. Consulted SLTs generally expressed agreement with the proposed terminology and a willingness to adopt it in practice. Existing terminology for childhood SSD provides a good basis for clinical decision-making. A modified version of Dodd's (2005) terminology was found to be acceptable to UK SLTs. There is an evident overlap of SSD with CATALISE terminology. However more detailed and specialist terminology than 'DLD (phonology)' is required to support clinical decision-making. It is proposed that endorsement by the UK Royal College of Speech and Language Therapists would obviate the need for a Delphi process. What is already known on this subject Over nearly a hundred years, as our knowledge and understanding of speech sound disorder (SSD) has increased, so has the terminology that is used to describe those disorders. Current terminology not only describes subtypes of SSD but can also signpost us to effective interventions. With the publication, in 2017, of phase 2 of CATALISE a new term of 'developmental language disorder (DLD) (phonology)' was introduced with the unintentional consequence of challenging more specific descriptive terms for SSD. What this paper adds In the context of CATALISE and DLD (phonology), the history and nature of SSD terminology are reappraised. Building on the model of DLD developed in CATALISE, a tiered model that supports descriptive diagnosis and signposts intervention is proposed for discussion. Clinical implications of this study The proposed model of terminology for SSD provides descriptive and detailed labels that will support accuracy in differential diagnosis of developmental SSD by speech and language therapists. Furthermore, a decision-making tree for SSD demonstrates the pathway from diagnostic use of the terminology to the selection of evidence-based, effective interventions.

Children with speech sound disorders (SSD) represent a large number of speech and language therapists’ caseloads. The intervention with children who have SSD can involve different therapy approaches, and these may be articulatory or phonologically based. Some international studies reveal a widespread application of articulatory based approaches in children with different SSD. In Portugal no survey has been previously conducted about speech and language therapists (SLTs) practices when working with children with SSD, so it is still unknown how SLTs treat children with SSD. This study aims to explore the use of different intervention approaches of SLTs in Portugal, and to describe the approaches most frequently used in treating children who have phonologically based SSD. Data collection was conducted through a questionnaire available on the web platform Advanced Communication and Swallowing Assessment (ACSA; http://acsa.web.ua.pt ), and data analysis was based on 88 responses, corresponding to 5% of the total Portuguese SLTs population. Results showed that the intervention approaches most used with children who have SSD are phonological awareness (97% of the participants), auditory discrimination (92%), meaningful minimal contrast therapy (75%) and parent-based work (58%). The great majority of SLTs combined several approaches in their intervention. There was also a high percentage of SLTs that used articulation based approaches, namely articulation work (31%) in cases of phonologically based disorders. Most (63%) SLTs used weekly interventions over a period of more than six months (51%). The data presented here agrees with the results obtained in South African, UK and USA studies in terms of the approaches most frequently used in intervention with children who have phonologically based SSD. Regarding the frequency and duration of intervention, there is a discrepancy between the results obtained and what is commonly used across research. The characteristics described by the Portuguese SLTs for establishing the differential diagnosis of SSD do not always reflect the evidence available in recent literature. The findings presented in this article revealed the intervention approaches that SLTs currently use to treat children with phonologically based SSD and the theoretical foundations that guide their clinical practice. This allows the reader to compare clinical practice of SLTs across countries and research studies.

ABSTRACTBackgroundChildren with speech sound disorders (SSDs) of unknown origin usually need high‐intensity speech intervention delivered by a speech and language therapist (SLT) and there is a rich evidence base focusing on these interventions. However, access to direct SLT services can be challenging, leaving many children with no timely support. To date there is no systematic review of possible interventions for children with SSD of unknown origin that do not require direct SLT input.AimsTo describe a protocol for a systematic review of non‐SLT‐delivered interventions for children with SSD of unknown origin.Methods and proceduresA systematic literature review will be performed following the preferred reporting items for systematic reviews and meta‐analyses (PRISMA) guidelines, by two academic SLTs who are topic experts and a subject librarian. The search will include electronic databases (including ASSIA, CENTRAL, CINAHL, The Cochrane Library, Embase, LILACS, MEDLINE, APA PsychInfo, PubMed, SCI, Scopus, SSCI) for peer reviewed studies published in English with no limits on publication date. Study selection will follow pre‐specified inclusion criteria: majority children with SSD of unknown origin; and exclusion criteria: interventions targeting signing, AAC, language or delivered by SLTs. The remaining studies will be assessed for risk of bias. Data will be extracted using comprehensive structured forms. A narrative and quantitative synthesis will be provided.Conclusions and implicationsThe results of this review will support SLTs to make evidence‐based decisions when supporting children with SSDs of unknown origin while managing long waiting lists and large caseloads. The systematic review will make recommendations for improved service delivery, suggesting whether clinical pathways for this client group may also include interventions not involving SLTs.Trial registrationThis systematic review protocol has been registered with PROSPERO, registration number CRD420251006629.WHAT THIS PAPER ADDSWhat is already known on this subjectThere is a wealth of information about the evidence base for interventions for children with speech sound disorders (SSDs) of unknown origin delivered directly by speech and language therapists (SLTs). However, there is limited information about the effectiveness of alternative interventions delivered by therapy partners or mediated via a digital tool.What this study adds to the existing knowledgeThis paper outlines the protocol for a systematic literature review on interventions for children with SSD that are not delivered by SLTs.What are the potential or actual clinical implications of this study?The results of this review will provide SLTs with the current evidence base for interventions for children with SSD that do not require their direct input, which they might consider for implementation while managing large caseloads or long waiting lists.

Classification systems in healthcare support shared understanding of conditions for clinical communication, service monitoring and development, and research. Children born with cleft palate with or without cleft lip (CP+/-L) are at high risk of developing cleft-related speech sound disorder (SSD). The way cleft-related SSD is represented and described in SSD classification systems varies. Reflecting on the potential causal pathways for different cleft-related speech features, including the role of speech processing skills, may inform how cleft-related SSD is represented in classification systems. To explore and reflect on how cleft-related SSD is represented in current SSD classification systems in the context of considering how speech processing skills and other factors may be involved in causal pathways of cleft speech characteristics (CSCs). Variation in the representation of cleft-related SSD in classification systems is described. Potential causal pathways for passive cleft- related speech features and different active CSCs are explored. The factors involved in the development and/or persistence of different active CSCs may vary. Some factors may be specific to children born with CP+/-L, but if speech processing skills are also involved, this is an overlap with other SSD subtypes. Current evidence regarding relationships between different speech processing skills and active CSCs is limited. Implications for the representation of cleft-related SSD in SSD classification systems are discussed. There are different categories of cleft-related speech features which are essential to understand and identify in children with cleft-related SSD to ensure appropriate management. Representation of these feature categories in classification systems could support understanding of speech in this population. Speech processing skills could be involved in the development and/or persistence of different active CSCs in individual children. Reflection and discussion on how cleft-related SSD is represented in classification systems in relation to other SSD subtypes may inform future iterations of these systems. Further work is needed to understand factors influencing the development and/or persistence of active CSCs, including speech processing skills. What is already known on the subject Cleft-related speech sound disorder (SSD) is commonly described as being of known origin. The features of cleft-related SSD have been described extensively and several authors have also examined factors which may contribute to speech development and outcomes in children born with cleft palate +/- lip. There is limited evidence regarding the role of speech processing in the development and persistence of cleft-related SSD. What this study adds This paper reflects on how cleft-related SSD is represented in SSD classification systems in relation to key feature categories of cleft-related SSD and possible causal pathways for passive features and active cleft speech characteristics (CSCs). The role of cognitive speech processing skills is specifically considered alongside other factors that may contribute to the development of active CSCs. What are the clinical implications of this work? Causal pathways for different features of cleft-related SSD may vary, particularly between passive and active features, abut also between different active CSCs. Speech and language therapists (SLTs) need to differentially diagnose passive speech features and active CSCs. Consideration of the role of different speech processing skills and interactions with other potentially influencing factors in relation to active CSCs may inform clinical hypotheses and speech and language therapy (SLT) intervention. Representing key features of cleft-related SSD in classification systems may support understanding of cleft-related SSD in relation to other SSD subtypes.

ABSTRACTBackgroundSpeech sound disorder (SSD) is broadly defined as difficulty producing speech sounds in childhood. It can have a lasting impact on academic outcomes and well‐being, making effective early intervention vital. Speech and language therapists (SLTs) consider parental involvement—particularly supporting their child with home practice—as essential to a child's progress. Relationships between SLTs and parents are known to facilitate this engagement. However, there is a significant gap in the literature regarding parents’ perspectives, and little is known about what parents perceive to be most effective in supporting home practice. Understanding these perspectives is crucial for designing interventions that are both feasible and meaningful for families.AimTo explore the perspectives of parents of children with SSD aged ≤5;11, about their experiences with speech and language therapy intervention sessions and home practice.Methods and ProceduresThis study used qualitative methodology. Nine parents, recruited via social media, professional networks and a university clinic, participated in focus groups or 1:1 interviews. A group of children, aged 4–6, who had lived experience of SSD, speech and language therapy and home practice were consulted to design the topic guide and inform data analysis. Discussions were recorded, transcribed verbatim and analysed using Reflexive Thematic Analysis.Outcomes and ResultsFour main themes were constructed as follows: (1) Building positive therapeutic relationships is fundamental to families’ experiences and creates the foundation for successful home practice. (2) SLTs need to employ a wide range of skills and knowledge, including a multi‐modal approach to empower parents and develop their capability. (3) Clear communication is key for shared power, understanding of roles, active involvement and effective home practice. (4) Factors outside an individual's control can impact parents’ attitudes towards, and engagement with, home practice.Conclusions and ImplicationsWe conclude that relationships between SLTs and parents, and the skills required to build these, underpin parental motivation to engage in home practice. To maximise parental capability, SLTs ensure that parents understand not only what to do but why they are doing it, utilising a variety of methods. Whilst some barriers for home practice are out of the SLT's control, using all opportunities to develop the motivation and capability of the parents is required. To achieve this, service delivery models may need to be reconsidered.WHAT THIS PAPER ADDSWhat is already known on this subjectSSD that persists into school years can have lasting implications for a child's academic outcomes and well‐being. Effective and efficient early intervention is essential. SLTs and parents agree that working together, including parental delivery of home practice, is important for a child's progress. Little is known about how parents experience and perceive what SLTs do within intervention sessions to ensure parents feel confident and capable of delivering effective home practice.What this paper adds to existing knowledgeThis is the first study to explore parents’ perceptions and experiences of what SLTs do within direct intervention sessions for young children with SSD and how this supports parents to become implementors of intervention for their child at home. Findings suggest that parents benefit from SLTs using a range of teaching and coaching approaches, including clear instructions and active involvement, to ensure parents feel confident and capable at home. Relationships between the parent, SLT and the child are highly valued by parents, and are fundamental for parental engagement with home practice.What are the potential or actual clinical implications of this work?SLTs prioritising building effective relationships with parents and children can support parental motivation for home practice. SLTs can work with parents to increase opportunities for home practice by building it into their daily lives, including working with other family members. To maximise parental capability, it is important to ensure that parents understand not only what to do but why they are doing it, utilising a variety of methods. To achieve this, service delivery models may need to be reconsidered.

Speech sound disorders (SSDs) are the most common form of communication disorders in children. SSD have an impact on children's abilities to make themselves understood to their listeners and can influence a child's social and emotional well-being as well as their academic achievements. Therefore, it is important to identify children with an SSD early, in order to provide appropriate intervention. A wealth of information on best practice in the assessment of children with SSD is available in countries where the speech and language therapy profession is well established. In Sri Lanka, there is a paucity of research evidence supporting assessment practices that are culturally and linguistically appropriate in SSDs. Therefore, clinicians rely on informal assessment methods. There is a need to understand more about how clinicians in Sri Lanka assess this caseload in order to get general agreement regarding comprehensive and consistent procedures for assessment of paediatric SSD in Sri Lanka. This would support speech and language therapists' (SLTs') clinical decision-making in relation to choice of appropriate goals and intervention for this caseload. To develop and gain consensus on an assessment protocol for Sri Lankan children with SSD that is culturally appropriate and based on existing research. A modified Delphi method was utilised to gather data from clinicians currently working in Sri Lanka. The research involved three rounds of data collection, exploring current assessment practices in Sri Lanka, ranking these in order of priority and establishing consensus on a proposed assessment protocol. The proposed assessment protocol was based on the results of the first and second rounds as well as previously published best practice guidelines. The proposed assessment protocol achieved consensus in relation to content, format and cultural appropriateness. SLTs affirmed the usefulness of the protocol within the Sri Lankan context. Further research is required to assess the feasibility and effectiveness of this protocol in practice. The assessment protocol supports practicing SLTs with a general guide to assessing children with suspected SSDs in Sri Lanka. The application of this protocol built upon consensus enables clinicians to improve their individual practice patterns based on best practice recommendations in the literature and the evidence on culturally and linguistically appropriate practices. This study has identified the need for further research in this area, including the development of culturally and linguistically specific assessment tools that would complement the use of this protocol. What is already known on the subject The assessment of children with speech sound disorders (SSDs) requires a comprehensive and holistic approach due to their heterogeneous nature. Although there is evidence to support the assessment of paediatric SSDs in many countries where the profession of speech and language therapy is established, there is limited evidence to support the assessment of children with SSDs in Sri Lanka. What this study adds This study provides information about current assessment practices in Sri Lanka and consensus on a proposed culturally appropriate protocol for the assessment of children with SSDs in this country. What are the clinical implications of this work? The proposed assessment protocol provides speech and language therapists in Sri Lanka with a guide for assessment of paediatric SSDs to support more consistent practice in this area. Future evaluation of this preliminary protocol is required; however, the methodology used in this research could be applied to the development of assessment protocols for other range of practice areas in this country.

ABSTRACTBackgroundChildren with speech sound disorder (SSD) are at risk of long‐term adverse consequences if appropriate intervention is not provided in a timely way. Although there are interventions of proven efficacy, these are often not implemented with good fidelity in clinical practice. Children with SSD in the United Kingdom are commonly managed in care pathways within NHS and independent speech and language therapy services. It is not known which care pathways are most effective because there is currently no systematic recording or analysis of intervention outcomes for children with SSD.AimsThe objective of the MISLToe‐SSD study is to develop an evidence‐based protocol for collecting routine data on a large‐scale so that UK SSD care pathways can be evaluated for clinical‐ and cost‐effectiveness. The development of the core outcome set (COS) is reported here.Methods and ProceduresFollowing the Core Outcome Measures in Effectiveness Trials methodology, a modified Delphi process was used to reach a consensus on a COS for SSD interventions. The Delphi process comprised two online survey rounds and one online meeting. Anonymity between panel members was maintained during the online survey rounds. Round one required a consensus of ≥50%, rising to ≥75% in round two.Outcomes and ResultsA group of 66 UK speech and language therapists identified as experts in SSD by their peers were recruited through specialist clinical and research networks. A long list of 30 outcome statements was reduced by consensus to a final list of seven outcomes with associated measurement instruments. Increased speech intelligibility was agreed as the primary outcome by 100% of panel members. Six secondary outcomes were identified.Conclusions and ImplicationsThe final COS can be used in future research to evaluate care pathways and intervention effectiveness for children with SSD. Furthermore, it provides a basis for measuring outcomes in future intervention trials for SSD.WHAT THIS PAPER ADDSWhat is already known on this subjectSpeech and language therapy services in the United Kingdom are ideally placed to contribute to large‐scale evaluations of services provided for children with speech sound disorder (SSD) due to the computerised routine collection of data related to client management and interventions. However, these routine data cannot currently be used to evaluate the effectiveness or efficiency of interventions for children with different subtypes of SSD due to a lack of uniformity in data collection. There are no agreed and validated outcomes, outcome measures, diagnostic protocols or agreed labels and definitions for the evidence‐based interventions that can be used by services across the United Kingdom.What this study adds to existing knowledgeBuilding on information from an umbrella review and practitioner workshops, a modified Delphi process with 66 SSD expert speech and language therapists from across the United Kingdom, was utilised to develop a core outcome set (COS) and a minimum dataset of common data elements.What are the potential or actual clinical implications of this study?The COS and minimum dataset can be used by speech and language therapy services to collect routine data in a way that can contribute to large‐scale evaluations of the effectiveness and efficiency of interventions for children with SSD.

ABSTRACTIntroductionChildren with moderate to severe speech sound disorder (SSD) need intensive therapy to increase intervention effectiveness and efficiency. However, worldwide speech and language therapists (SLTs) report that it is difficult to implement recommended intervention intensities in clinical practice. Supporting parents/carers to deliver home‐intervention, facilitated through digital tools, has the potential to circumvent these difficulties and increase practice intensity. This realist evaluation builds on our earlier realist review on intensive, digital, parent‐implemented interventions for children with SSD through exploring the experiences of stakeholders to optimally understand what might work best, for whom, and why in clinical practice.MethodsWe undertook a realist evaluation to test and refine our initial programme theories developed in our earlier realist review through focus groups with key stakeholders. Five focus groups were conducted with SLTs (n = 22), and two focus groups with parents/carers of children with SSD aged 4–5 years (n = 6). A realist methodology approach was used to collect and analyse the data, including the development of context‐mechanism‐outcome configurations. Middle‐range theories of adult‐learning, self‐efficacy and parenting styles were used to develop our theoretical thinking.ResultsProgramme theories from the earlier realist review about how the intervention works were refined, refuted, or confirmed. The refined theories are presented across three areas to demonstrate the journey of engaging in a digital, intensive parent‐implemented intervention: (1) Readiness to engage; (2) Implementation of the intervention; and (3) Sustaining momentum. The theories offer insight into mechanisms that support and train families to engage in home‐practice through digital tools, including important contextual factors needing consideration in implementation.ConclusionDigital, intensive, parent‐implemented interventions for children with SSD have the potential to improve the effectiveness and efficiency of SLT services in certain contexts and improve children's outcomes worldwide. Mechanisms of change, and impactful contexts at each point of the journey of involvement need consideration to successfully empower and support parents/carers and their children with SSD.WHAT THIS PAPER ADDSWhat is already known on this subjectClinicians worldwide face challenges providing the optimal intensity of intervention for children with SSD. Studies have explored parent‐implemented interventions and digital tools to increase intervention intensity. These new and innovative service delivery models can be effective in certain circumstances; however, further exploration is required to understand why digital, parent‐implemented interventions may work, for whom, and how.What this study addsThis paper uses a realist methodology approach to capture stakeholder experiences to develop underpinning theories about digital, intensive, parent‐implemented interventions for children with SSD. The new theoretical insight from this realist evaluation builds upon our understanding of what makes this intervention work (or not), who it works for, and why.What are the clinical implications of this study?SLTs and health services will have a clearer understanding of how to support parents/carers to implement intensive home‐intervention through digital tools, and which factors impact its effectiveness. New understanding demonstrates how digital tools to support parents/carers have the potential to support more intensive practice for children with SSD.

Purpose: The purpose of the present study was to gain insight into the solution-oriented modalities utilized by Speech and Language Therapists (SLTs) in clinical diagnosis and intervention for children with Speech Sound Disorder (SSD). Method: A constructivist modality was employed within a qualitative paradigm, with phenomenology serving as the main study methodology to delve into how SLTs administer therapy to children with SSD. Interpretive phenomenology was chosen as the analytical modality to uncover the often unconscious meanings embedded in common life practices. 12 SLPs with professional experience ranging from 1 to 20 years participated in the research. The research data were collected through online access and semi-structured one-on-one interviews between the researcher and the participants. The semi-structured interviews were transcribed, and a dataset was created.To strengthen the validity of the research findings, direct quotes from the participants were included when compiling the report. To ensure the consistency of data analysis, the data was analyzed by another field expert other than the researchers. Results: The findings indicate that SLTs employ a range of evaluations for diagnosing SSD, often complemented by observation and a case design approach. The selection of intervention strategies is influenced by factors such as the child's preferences, age, specific diagnosis, and severity of the disorder. Additionally, SLTs emphasize the significant role of parents in both the diagnosis and intervention processes. Conclusion: These findings underscore the necessity for (a) distinguishing which condition, SSD or any accompanying disorders, is more pronounced in the child, (b) the development of a fast and easy-to-apply comprehensive differential diagnosis tool to assess daily life participation, (c) updates to existing evaluation tools, and (d) the dissemination of practices/training to promote the preference for evidence-based intervention modalities in clinical practice for SSD.

Objective: To investigate speech and language therapists’ current practice in the selection of intervention targets for children with speech sound disorders. Method: Questionnaires were used to elicit information from 88 speech and language therapists working in the Republic of Ireland about their selection of intervention targets in the treatment of speech sound disorders. Main results: The majority (73%) of therapists placed a high priority on selecting stimulable sounds as intervention targets. Around half (52%) placed a high priority on earlier developing sounds with a minority prioritizing later developing sounds (10%) and non-stimulable sounds (14%). Speech and language therapists’ years of experience did not have a significant impact on their selection practices. However, the amount of continuing professional development a speech and language therapist had in the area of speech sound disorders did have a significant effect on target selection. Conclusion: The speech and language therapists in this study used clinical experience and traditional practices, such as stimulability, to select intervention targets in the treatment of speech sound disorders. However, there is research evidence to show that the selection of non-traditional intervention targets, such as non-stimulable and later developing sounds, can result in more system-wide generalisation. Speech and language therapists may benefit from increasing their knowledge about current theories and intervention research relevant to target selection.

Speech sound disorders (SSDs) are broadly defined as difficulty producing speech sounds in childhood. Reported prevalence of SSD varies from 2.3% to 24.6%, depending on how SSD is defined and the included age range. SSDs that do not resolve before age 8 can have a lasting impact on a child's academic achievements. The intensity of intervention for SSD is important to ensure effectiveness. However, there is a gap between the evidence base for intensity and speech and language therapists' (SLTs) clinical practice. One way that SLTs try to bridge this gap is by working with parents. SLTs believe that working with parents/caregivers is vital for a child with SSD to make progress. To conduct a scoping review of the literature to provide a comprehensive picture of the perceptions, experiences and strategies underpinning collaborative working between SLTs and parents/caregivers of children (aged ≤ 5 years 11 months) with SSD to increase intervention intensity at home. This scoping review was completed in accordance with PRISMA-ScR guidelines. A systematic search of PubMed, PsycInfo, CINHAL, Web of Science, EBSCOhost and EThOS was conducted using synonyms of three key terms: SSD, Therapy, Parents. Key journals and papers were hand searched for unique papers. A total of 29 papers were included for review. Data were analysed using thematic synthesis to develop themes. These themes are discussed using the PAGER framework to identify advances, gaps, evidence for practice and areas for future research. Seven key themes were identified: individualization, setting expectations, daily life, parental knowledge, parental involvement, therapeutic relationships and supporting parents to deliver home practice. There has been an acceleration of research around working with parents of children with SSD, with increased consideration of effective adult coaching techniques. Parents value the parental and child relationship with the SLT and feel this supports the success of home practice. There is a need for further research, and guidance for SLTs working with parents of children with SSD to enable them to support parents to deliver home practice effectively. Emerging evidence supports the value of SLTs and parents working together to support home practice for children with SSD. The review highlighted the importance of SLTs allocating time to build positive therapeutic relationships with parents to support engagement in therapy. Approaching intervention, in particular, home practice, flexibly and in collaboration with parents, allows parents to fit home practice into their daily lives. Providing clear information to parents supports the fidelity of, and engagement in, home practice. What is already known on the subject There is a gap between what is recommended in the evidence base for intervention intensity for children with SSD and current clinical practice worldwide. SLTs try to bridge this gap through home practice and believe that working with parents/caregivers is vital for children with SSD to make progress. However, little is known about the best ways for SLTs to work with parents for this population. What this paper adds to the existing knowledge Training parents to be implementers of intervention in a personalized and flexible way is important and valued by parents and SLTs. Parents value understanding the clinical rationale behind the intervention approach and benefit from explicit instructions for home practice, including discussion, written information, observation and feedback. Therapeutic relationships take time to develop and impact parental engagement in home practice. What are the potential or actual clinical implications of this work? The findings of this study highlight existing knowledge which will support SLTs to work optimally with parents to implement home practice for their child with SSD. It highlights the importance of taking time to foster working relationships with parents to support effective home practice. The review identifies gaps in the current skills and knowledge of SLTs, highlighting the need for further research, support and guidance for SLTs in their work with parents, as well as implications for the development of the SLT pre-registration curriculum.

Interprofessional Collaboration Between Audiologists, SLPs

According to the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, diagnosis of speech sound disorder (SSD) requires a determination that it is not the result of other congenital or acquired conditions, including hearing loss or neurological conditions that may present with similar symptomatology. To examine peripheral and central auditory function for the purpose of determining whether a peripheral or central auditory disorder was an underlying factor or contributed to the child's SSD. Central auditory processing disorder clinic pediatric case reports. Three clinical cases are reviewed of children with diagnosed SSD who were referred for audiological evaluation by their speech-language pathologists as a result of slower than expected progress in therapy. Audiological testing revealed auditory deficits involving peripheral auditory function or the central auditory nervous system. These cases demonstrate the importance of increasing awareness among professionals of the need to fully evaluate the auditory system to identify auditory deficits that could contribute to a patient's speech sound (phonological) disorder. Audiological assessment in cases of suspected SSD should not be limited to pure-tone audiometry given its limitations in revealing the full range of peripheral and central auditory deficits, deficits which can compromise treatment of SSD.

When planning evidence-based intervention services for children with phonology-based speech sound disorders (SSD), speech and language therapists (SLTs) need to integrate research evidence regarding service delivery and intervention intensity within their clinical practice. However, relatively little is known about the optimal intensity of phonological interventions and whether SLTs' services align with the research evidence. The aims are twofold. First, to review external evidence (i.e., empirical research evidence external to day-to-day clinical practice) regarding service delivery and intervention intensity for phonological interventions. Second, to investigate SLTs' clinical practice with children with phonology-based SSD in Australia, focusing on service delivery and intensity. By considering these complementary sources of evidence, SLTs and researchers will be better placed to understand the state of the external evidence regarding the delivery of phonological interventions and appreciate the challenges facing SLTs in providing evidence-based services. Two studies are presented. The first is a review of phonological intervention research published between 1979 and 2016. Details regarding service delivery and intervention intensity were extracted from the 199 papers that met inclusion criteria identified through a systematic search. The second study was an online survey of 288 SLTs working in Australia, focused on the service delivery and intensity of intervention provided in clinical practice. There is a gap between the external evidence regarding service delivery and intervention intensity and the internal evidence from clinical practice. Most published intervention research has reported to provide intervention two to three times per week in individual sessions delivered by an SLT in a university clinic, in sessions lasting 30-60 min comprising 100 production trials. SLTs reported providing services at intensities below that found in the literature. Further, they reported workplace, client and clinician factors that influenced the intensity of intervention they were able to provide to children with phonology-based SSD. Insufficient detail in the reporting of intervention intensity within published research coupled with service delivery constraints may affect the implementation of empirical evidence into everyday clinical practice. Research investigating innovative solutions to service delivery challenges is needed to provide SLTs with evidence that is relevant and feasible for clinical practice.

In Portugal, the routine clinical practice of speech and language therapists (SLTs) in treating children with all types of speech sound disorder (SSD) continues to be articulation therapy (AT). There is limited use of phonological therapy (PT) or phonological awareness training in Portugal. Additionally, at an international level there is a focus on collecting information on and differentiating between the effectiveness of PT and AT for children with different types of phonologically based SSD, as well as on the role of phonological awareness in remediating SSD. It is important to collect more evidence for the most effective and efficient type of intervention approach for different SSDs and for these data to be collected from diverse linguistic and cultural perspectives. To evaluate the effectiveness of a PT and AT approach for treatment of 14 Portuguese children, aged 4.0-6.7 years, with a phonologically based SSD. The children were randomly assigned to one of the two treatment approaches (seven children in each group). All children were treated by the same SLT, blind to the aims of the study, over three blocks of a total of 25 weekly sessions of intervention. Outcome measures of phonological ability (percentage of consonants correct (PCC), percentage occurrence of different phonological processes and phonetic inventory) were taken before and after intervention. A qualitative assessment of intervention effectiveness from the perspective of the parents of participants was included. Both treatments were effective in improving the participants' speech, with the children receiving PT showing a more significant improvement in PCC score than those receiving the AT. Children in the PT group also showed greater generalization to untreated words than those receiving AT. Parents reported both intervention approaches to be as effective in improving their children's speech. The PT (combination of expressive phonological tasks, phonological awareness, listening and discrimination activities) proved to be an effective integrated method of improving phonological SSD in children. These findings provide some evidence for Portuguese SLTs to employ PT with children with phonologically based SSD.