SeeHearSpeak Podcast

00:00:11 Tiffany Hogan: Welcome to See Hear Speak Podcast Episode 36. I’m happy to report that I’ve finished active treatment for breast cancer and am cancer free! I’ll be taking the next few months to recover from this crazy year of treatment. In the meantime, I’m grateful to guest hosts for keeping the content coming to you. In this episode guest host Kelly Farquharson returns. She talks with Dr. Katy Cabbage and Dr. Shari Deveney about treatment for pediatric speech sound disorders. Specifically, they discuss the importance of understanding what treatment approach to use with various profiles, the most misunderstood treatment approaches, and advice for practicing clinicians just starting to learn more about treatment for speech sound disorders. I’m thankful to Kelly, Katy, and Shari for taking the time to share with SeeHearSpeak listeners. Speaking of listeners, thank you for listening! And don’t forget to check out our website, www.seehearspeakpodcast.com, to sign up for email alerts for new episodes and content, read a transcript of this podcast, access articles and resources that we discussed, and find more information about our guests. And, if you like this podcast, don’t forget to subscribe and leave a positive rating in apple podcast or wherever you are listening.

00:01:39 Kelly Farquharson: Welcome to today's episode of See Hear Speak podcast. My name is Kelly Farquharson, and I am your guest host today. Today we're gonna be talking about treatment for speech sound disorders with two of my very favorite people and very favorite researchers, Dr. Shari DeVeney and Dr. Katy Cabbage. So would each of you please introduce yourselves?

00:02:01 Katy Cabbage: Yeah, so I can go first. So I'm Katy Cabbage, and I am currently at Brigham Young University in beautiful Provo, Utah, and I'm an assistant professor there. I just finished my fourth year on faculty at BYU. I study the intersection between speech sound disorders and literacy, that's kind of my interest area, and so I do have a research lab called the CabLab at BYU, and I work with a lot of undergraduate researchers, that's kind of the focus at BYU. And everything we do in my lab is somehow related to speech sound disorders, how those kids do or do not have success learning to read, and what's going on underneath the hood? How are these kids processing speech sounds, how are they thinking about speech sounds, and how do we ultimately get better at helping them produce speech sounds correctly?

00:02:59 KF: Awesome, thank you.

00:03:02 Shari DeVeney: Okay. And I am Shari DeVeney and I'm an Associate Professor at the University of Nebraska at Omaha and Special Education and Communication Disorders. And I do wanna say thank you so much for having us, I'm so excited to talk about speech sound disorders with both of you. I know it's one of our favorite topics. So I'm really looking forward to sharing information with the See Hear Speak listeners as well. So I do wanna mention that before I finished my doctorate work in speech language pathology, I was a practicing clinician for about 10 years, working mainly in early childhood and K-12 educational settings, and I think we've all had that clinical experience, and I think it was really important. I think it's really framed my lens, especially as an educator and a researcher now. So right now, I teach course work on a variety of different topics, but including pediatric speech sound disorders, language disorders and language learning disorders like dyslexia, and my research focus does include speech sound disorders, particularly in young pediatric populations.

00:04:11SD: It's no secret, I'm a big fan of early intervention, it's really a passion of mine, and I think the SLP's work with young children is truly valuable, and I wanna do what I can as an educator, as a researcher, to really champion that work and be a part of the development of professional evidence base and its dissemination to support really high quality service provision for young children who could benefit from our help. So my lab at UNO is the Toddler Communication Lab. And as I said, I'm really happy to be here, so thank you, Kelly and Tiffany for having us.

00:04:47 KF: That's awesome, that's so great. Thank you both for that introduction. And I think a fun fact about us, in addition to thank you for talking about our clinical experience, I think that's an important thing to call out for any researcher because it really does help to shape the direction that we take sometimes in our research that we were all practicing SLPs before we went back for our PhDs, and we all did our PhDs at the same time at the University of Nebraska in Lincoln, so that's how that we met.

00:05:10 KC: We did.

00:05:12 SD: Yeah.

00:05:13 KF: Yeah. So we were a doc student group together with a cadre of other wonderful people, but it's very exciting to now be pretty far out on the other side of that.

[laughter]

00:05:26 SD: That's the great part. We're done.

[laughter]

00:5:30 SD: No, it was a great experience. A lot of good came out of that, for sure.

00:05:34 KC: Yeah, and I'm really glad, Shari, that you mentioned the clinical background, because I think to your point, so I'm a former school-based SLP and yeah, I think of those kids all the time in this work that we currently do, and I think that that has really shaped the direction that my research has gone because of those kids that I worked with in the schools.

00:05:54 KF: Well, I think one reason that I had you two in mind to talk to, in addition to just loving talking to the two of you, kind of comes from that exact idea of the ways in which your clinical experience has shaped the direction that your research has taken and one thing in particular that has been of interest to me that you guys have collaborated on together is kind of this series of presentations that you've done at ASHA now at the ASHA Convention every year about selecting the right treatment approach for speech sound disorders. And the times that I've gotten to go to that presentation, it is standing room only, and you two have filled very, very large ballrooms with people who are really interested in this idea of which treatment approach do we select? How do we apply it? How do we know we're doing the right one, [chuckle] and monitoring that progress along the way, so I'm super curious of how you started that idea and how you got to the point of filling large ballrooms of people of clinicians wanting to hear from you. So how did that start?

00:06:59 KC: Well, clearly we feel ballrooms because of our just magnanimous personalities.

00:07:05 SD: Yes, it's our dynamic presentation style more than anything. Well, honestly, a few years ago, Katy and I were both talking about the kinds of questions that we've been fielding from practicing clinicians and from former students about speech sound disorder treatment, and as we mentioned, we both teach course work and speech sound disorder for students who obviously haven't started their careers yet. But we realize a lot of folks have had basic course work and speech sound disorder as part of their initial training for the profession, were out working and now have some questions about what else they could be doing, so some were looking for a deeper understanding of why we do what we do, some had students on their case load that maybe they weren't feeling particularly confident about treating for a variety of reasons.

00:07:56 SD: And I think it kind of boils down to education in our profession is really... It's all about bidirectional learning, so often we go in one direction where we start teaching a subject academically first and then applying it to clinical practice, but the learning process can also work the other way too, so we encounter things in clinical practice that lead to questions and give us motivation for continued learning. So Katy and I really got to talking and thought about how great it would be to address these questions more systematically for clinicians in the field. So it's kind of like in class when one student asks a question, chances are that other people are wondering the same thing, and can really benefit from hearing those answer. So we decided to put together a proposal for our talk at ASHA when it was in LA in 2017 on intervention decisions for children with speech sound disorder, and that was pretty well received. And then we were invited to speak at ASHA in Boston the next year about target selection.

00:08:58 SD: And then that talk also was pretty well attended, and so we had the opportunity to kind of expand on these topics for a short course presentation then in ASHA in 2019, and also since then, we have graciously had some opportunities to write about updated research findings and evidence that informs clinical practice for pediatric speech sound disorder treatment, and we're happy to share those links to those papers in the notes section, in the notes section for the podcast. I also just wanna say, I think it's been really fun... Is that a word we can use to describe this collaboration, Katy?

00:09:35 KC: Oh, I would use that word for sure.

[laughter]

00:09:38 SD: But it's been really fun to lean into our roles in higher education as researchers and share the information that we've come across and dug into with practicing clinicians, so we both have really spent a lot of time combing through research and reading up on expert opinions related to speech sound disorder treatment and that was time that we didn't have as practicing clinicians for those kind of tasks, and so hopefully being able to kind of pull that together and share those with people, that can really be beneficial and help them more effectively approach their work, and that's really I think what drives us.

00:10:16 KC: Yeah, I would totally agree, and I think it's been really fun as we've continued to do this, the opportunity to interact so directly with so many clinicians from all over the country and get their feedback like, "These are the things I'm trying... " And it's just developed this lovely conversation around speech sound disorder intervention, I think both Shari and I have just this real passion for helping SLPs be confident in the decisions that they're making.

00:10:45 KF: I love that so much, and the presentations have just been absolutely fantastic, and I am going to... In addition to the articles that you guys have written on this topic, which are excellent, I'm also going to get a copy of a handout from that first ASHA presentation that we can share with the listeners as well. So we'll post the PDF on that on the website as well, so thank you for offering to share that. So then a question I have related to this idea of all the digging you've been doing, right, so you've been... I love that you're thinking about this from a perspective of leaning into that opportunity and really just reading in depth and breadth across different therapy approaches and treatment approaches. So across your research and across your readings, and now your thinking and your presenting, have you landed on an approach that is your favorite? So do you have a favorite treatment approach?

00:11:41 KC: Oh goodness, that is a loaded question for me, [chuckle] 'cause there are lots of approaches out there, and it's one thing that I'm constantly teaching my students is, "There are so many approaches out there, and there are so many kids out there, and my favorite approach is the approach that's the right approach for that kid," and I think that's one of the things that's been so fun as I've learned and really dug into all these different approaches, I think... And Shari, and Kelly, you also can add to what you think, but I think that every approach has merit and when matched to the right kid, it is exactly the right approach for that kid. So I know that's kind of a cop-out answer. [chuckle]

00:12:22 KF: No, it's not, I love that.

00:12:25 KC: But if pressed, I think that the approach that has really changed my paradigm clinically, and this actually, that has to do with the targets that you're choosing to work on in therapy. And I remember back in 2007, I went to my very first ASHA and I went to a short course on complexity that Judy Garrett talked at. And that was this kind of watershed moment for me clinically, when learning this idea that what if we chose targets that were kind of above where a kid was at developmentally, and that was such an intriguing idea to me, and as I've dug more into complexity and used it clinically... Importantly, it is not the right approach for every kid, but I think for the kid, that complexity, which we talk about in some of the papers that we've written, this idea that if you choose complex targets to work on, that the rationale behind that is, if you have a kid who's missing a lot of phonemes and you choose a complex target, you as that child is acquiring that target, they acquire other targets that are less complex.

00:13:37 KC: And that idea was paradigm-shifting for me, because it really... It taught me to think about, what's my goal here with this kid? Am I trying to get one sound at a time? Is there a way to get more than one sound? So I think that for me, that was a very... It's hard to say that's my favorite approach because it's not the right approach for every kid, but for the kid that it is the right approach for, it's an awesome idea.

00:14:02 KF: Yes, I love that. And I first learned about the complexity approach... My phonology professor in graduate school was Adele Miccio who has since passed away. She died in 2009, but she was a student of Judy Garrett's, and so she talked a lot about the complexity approach, so... Yeah, I love that approach too.

00:14:21 KC: I was gonna say, what's funny about it that after that ASHA, I remember flying home on the plane, I'm like, "Oh my goodness... " All my kids, we're gonna start targeting complex targets... And that lasted about two days. I'm like, wait a minute. But there was one kid in particular in that group, Austin, I'll always remember Austin, for him, I had just been working with him and working with him and we were making no progress, and for him, he suddenly just made tons of progress, and for him it was the right approach, so...

00:14:50 KF: Yes, exactly.

00:14:51 SD: I just wanted to say too... [chuckle] I love hearing you talk about the complexity approach, Katy, and I remember there was one time we were presenting together, I think we were at the state convention in Nebraska a couple of years ago, and you were presenting on your section... I remember I'm up there copiously taking notes because I think it's a really intriguing approach, but I think it does take... You almost need repeated exposures to it before you can really kinda wrap your mind around and think like how would this work clinically for students. But I think you do a really great job of explaining it, so I think it can really...

00:15:27 KC: It's just so fun to talk about.

00:15:28 SD: Yeah, yeah. You can tell, you can really... Your passion really comes through. But it really has helped me have a deeper understanding of that approach too, just in our conversations and listening to you share about it. For me, I'm gonna interpret the word favorite pretty liberally...

[laughter]

00:15:52 SD: Because the approach that I wanna talk about isn't necessarily my most loved approach but is certainly ubiquitous to our field, and I think that there are some misunderstandings about it that I also wanted to kind of... I just wanna use this as a platform to talk about it a little bit, so the approach that I'm gonna talk about is one of our oldest speech sound disorder intervention approaches on record, it's still used very frequently in clinical practice with both pediatric and adult populations, and as I mentioned, it's very ubiquitous to our field, it's just... It's out there, people are using it all the time. And that approach is drum roll...

[laughter]

00:16:33 SD: No, just kidding! The traditional articulation therapy approach, which I think should otherwise be known as the vanilla ice cream approach of speech sound disorder intervention, it really just seems like it's everybody's default choice when nothing else sounds good, let's go with that one. And it's certainly been around for a long time, I believe it was even introduced back in the late '30s.

00:16:58 KC: Yeah, I think that's right.

00:16:59 SD: It's used by a lot of SLPs today to remediate speech sound disorders all the way from pre-schoolers through adults. In fact, in 2013, Brumbaugh and Smit, they surveyed hundreds of SLPs working with preschoolers and found that over 80% of those SLP surveyed used this approach either always or sometimes with their pre-school population, so there's obviously a lot of strengths and unique features to it, and that's why people are drawn to it, it's got this logical sequential progression, we really like that as SLPs, that air sounds are treated individually, so one after the other. So we have this kind of vertical attack strategy that works really great with clients of all ages who have a limited number of errors that are articulatory-based, and it has this emphasis on practice and repetition, and it's adaptable, it's flexible, so a lot of people love it, but I wish [chuckle] that people knew a little bit more about it, and I think there's a lot of nuances to it that kinda get glossed over, so I'm gonna share four things...

00:18:11 KF: Oh, okay.

00:18:22 SD: I know, so put your seat belts on. Here we go.

[laughter]

00:18:17 SD: So the first thing that I wish people understood a little bit better about the traditional articulation therapy approach is that there are some general guidelines to it and how to implement the approach, but there's very little in terms of concrete standardized details. So a lot of folks are probably implementing kind of a variety of sort of variations of this approach, so there's kind of a lack of consistency in how it's applied clinically. As I mentioned, there aren't a lot of standardized pieces to it, so like the reinforcement schedule, even the criteria that we may set for mastery, data collection, guidelines, all of that is pretty loosely defined. And so that's the first thing I wanted to mention.

00:19:04 SD: The second thing is, it's been around for a long time, and it's really stood the test of time, even Kam I pointed out back in 2006 that this approach has been studied a lot, but what we don't know is it hasn't really been studied a lot in comparison to other treatment approaches, so we know it works, but what the verdict is still kinda out on is we don't know how well it works compared to another approach, so there's still a pretty big expanse out there that we could delve into on this approach. Thirdly, I did wanna mention that what we're implementing today does kinda get away a little bit from the original version of this treatment approach, so Van Riper, when he first introduced it, he had a much bigger emphasis on the auditory perceptual side of the intervention, and in today's clinical practice we're really primarily focused on the production piece.

00:20:07 SD: He also really limited his use of imitation for elicited productions to just kind of, the level of isolation and the syllables, and we're using invitation to really introduce a lot of different... To introduce target words at different higher levels of linguistic complexity, so I don't know which is right. [laughter] We still need some research on it, but there's certainly our differences there that I do think we need to explore so we can figure out what should we be doing that's gonna give us more bang for our buck clinically. And then finally... This is my last point. I think this approach probably should be used a little bit more sparingly in clinical practice than it currently is, it's really not a one-size-fits-all treatment approach, and even though it's really popular, it's not appropriate for all clients, particularly clients who have multiple errors and really compromised intelligibility. So it's honestly not that great for pre-schoolers, particularly those that have phonologically-based errors. So yeah.

00:21:12 KC: I always thought that was interesting in that the survey said that you referenced that it's 80% of pre-school-based SLPs, and when you think about pre-schoolers with speech sound disorders, generally, those are your highly unintelligible kids, those kids who are having multiple phonological processes, if we know they have a speech sound disorder at pre-school age, it's usually pretty severe. And so I think you're making a really good point that thinking about, what is the right approach for those kids? And I think you're right, that that may not be the traditional articulation approach, may not be the right approach at that age.

00:21:49 SD: Yeah, absolutely. And Jonathan Preston and Megan Leece, they wrote a really comprehensive and informative chapter about articulation interventions kind of more broadly, and Lynn Williams and her colleagues' second edition of their interventions for speech sound disorders and children's texts, and they did a great job of really splitting up the components and kind of breaking out what works and what are some major drawbacks, and one of the things they noted, a term they used was that often this approach is inappropriately over-applied in clinical practice.

00:22:20 KC: Yeah, yeah.

00:22:21 SD: So I really couldn't agree more. So that's why I wanted to share some thoughts on this one. I'll get off my soapbox. [laughter]

00:22:27 KF: No I love that. I actually really appreciate your liberal adaptation of the favorite there, because I think those are some really great points. And that book you mentioned, we'll link that book in the notes for this episode as well. I think you make some really great points about really some considerations to take... I think some of those could actually really be applied across treatment approaches, the points you're making, because it's the case that...

00:22:52 KC: Oh yeah.

00:22:53 KF: Some of them are widely applied inappropriately, and I think that's a really important point to keep in mind. Can I share my favorite?

00:23:03 SD: Yes...

00:23:04 KC: Please, absolutely.

00:23:05 KF: Okay, so my favorite treatment approach, although I do now feel, thank you, Katy, that I'm gonna couch it in, [laughter] it has to be the right one for the right boy child...

00:23:15 KC: Right, right.

00:23:17 KF: But multiple oppositions is my jam. I love that approach so much. I think it is... So for me, and I'll use your terminology again, Katy, it was a watershed moment for me, learning about multiple oppositions. I didn't learn about it until after I had graduated from my master's program at Penn State, and I was at a professional development. It was probably 2006, it might have even been 2007, that we had these shared watershed moments, Katy.

00:23:43 KC: Oh my goodness.

[laughter]

00:23:45 KF: I know. And it wasn't at Ashley, it was at a state professional development when I was in Pennsylvania, and Lynn Williams was presenting, and it was about multiple oppositions, and I was just enthralled by the idea that it really kind of extends this idea of a phonological pattern or phonological process. It kind of extends the idea to think about each individual child using these idiosyncratic patterns, and when it seems like there's not a pattern there, there actually really is, it's just not something that fits neatly into the package of like fronting or stopping or backing. It's this really linguistically-based and unique to the child pattern, and we can treat it accordingly. And that just... That really blew my world open, and I... That's when I first met Lynn Williams, and after that, invited her to come to our state convention again and present when I got involved in the state association there, and she and I have have been friends ever since because I just was so kind of obsessed with this approach and learning more about it and applying it and in a non-stalkerish way, became [laughter] friends with Lynn Williams.

00:24:55 KF: And so to learn a little bit more about multiple oppositions, you could listen to episode 34 of this same podcast, See Hear Speak Podcast, because I got the opportunity to interview Lynn and we talked all about it. So I'll kind of let that go here. But that is my favorite approach. I just love thinking about it and love the structure of it and how we can apply it. And so I think both of you raised some really interesting points as you're talking about your favorite approaches, and it made me wonder, what do you think is... Now that you've kind of thought about these approaches, you've talked to a lot of clinicians about these approaches and you've presented a lot, what do you think is really the most misunderstood about treating speech sound disorders?

00:25:37 KC: Yeah, I feel like here, I have a soapbox that I'm about to get on...

00:25:43 KF: Yay.

00:25:44 SD: You can borrow mine, there you go.

[laughter]

00:25:48 KC: It's interesting, I feel like sometimes in our field that when we think about kids with speech sound disorders, we have terms like, "Well, that kid is just attic," or that somehow this communication disorder is a simple communication disorder. And I don't wanna rank communication disorders and impact on quality of life. But I think that one of... For me, as I've talked with clinicians and in my own experience, one of the most misunderstood things about speech sound disorders treatment is that it's easy to correct speech sound errors. And I think we've all had the kid who made pretty fast progress and that's awesome, but we also have all had that kid that is working on R for five years and you're still not making any headway with that. And so I think there's this misconception that, "Well, those were just the easy kids to treat." And I think it's really important that we recognize that, first of all, this takes skill to correct speech sound disorders, speech sound disorder errors. In the schools, I am a big advocate for, we need to keep these kids on our case load. I know that's not always a very popular opinion, but...

00:27:09 KC: And the reason I really stand by that is there's no one else in the school setting that knows as much about speech sounds as we do there, and kids who have language disorders or other learning disabilities there, they need help from the SLP for sure, but there are also other professionals working with those kids. And the kids who have a speech sound disorder, there's no one else working on that speech sound disorder except for the SLP. And I think about all the kids that I worked with that for them correcting their speech sound errors had a massive impact on them.

00:27:46 KC: I think of a kid that I worked with, he was a high schooler, and he... I asked him, "What do you think about your speech?" and at that point, he wasn't able to say R, he was still working on that, and he said, "It doesn't bother me most of the time except at a dance when I can't get a girl to understand what my name is," and his name had an R in it. And I often think of that kid, 'cause I think for a lot of people, he looked like a just attic kid. He's just not saying R all the time." But for him, like that was important, that is impacting his quality of life, and I really... I hold that disclosure that he had with safe confidence because that was a very vulnerable moment for him to explain like, "This is why I gotta learn how to say R." And I just think...

00:28:35 KC: So that's one of my... I think that things that's most misunderstood about kids with speech sound disorders, that they are easy to treat, and I think that if... I would argue that the more we understand about different approaches, the more tools we have, they get easier to treat for sure, but that requires education on our part as clinicians to make sure that we are providing the best intervention for the right kid. And so I think that this... I hope, I would love to start a revolution that we don't think of these kids as just artic, that we think of these kids as whole human beings who want to be able to communicate clearly and in a way where other people can understand them and respect them for who they are. So...

00:29:25 KF: Is there room on that soapbox for two? [laughter]

00:29:27 KC: Yes, come on up, come on up.

00:29:29 KF: You bet.

[laughter]

00:29:32 KF: Oh my gosh, do I agree. I think anybody who has had the misfortune of having this conversation with me knows how much I hate that phrase, "just attic". I think it's so belittling, and I think it's belittling to the SLPs, 'cause as you're saying, it's so hard to treat these kids, and belittling to the kids, like that's... It's not our job to like order...

00:29:51 SD: Your problem isn't very serious.

00:29:53 KF: Yeah, yeah, right. Yeah, exactly, I love that. What about you, Shari? What do you think is the most misunderstood aspect of treating speech sound disorders?

00:30:01 SD: Well, actually, scoot over guys, 'cause I wanna get [laughter] on the "just attic" soapbox also. Room for three. Party of three. But I also wanted to mention, Katy, and I have had conversations about this too, but I think something that gets lost in the discussion when you talk about "just attic" is sort of the transitory nature of communication disorders and how what a child's presenting with can kind of change over time. And so I do think that that does kinda get lost in the shuffle, and that a child maybe who now as a fifth grader, looks like they're just attic and only working on really that pesky R sound, but they may have a whole history of speech and language involvement, and so there may be some residual issues that they're still kind of dealing with. And I think we're really doing a disservice when we don't think about our students more holistically, and thinking about the historical context too of what they're presenting with. So...

00:31:10 KC: Yeah, absolutely.

00:31:12 SD: So the other piece that I wanted to talk about here is really, just has to do also with this over-simplification of speech sound disorders, but I'll tell you whenever I'm beginning to teach my undergrad speech sound disorder course, I always ask the students to set goals for themselves, "What do you really wanna get out of our time together? What do you really wanna understand?" and almost like two or one, I shouldn't say that, it's probably not 100%, but there's a lot of them that they really wanna know what's the difference between articulatory-based and phonologically-based. So we talk about it, we explain it, but the thing is, I don't want people to get... I don't want them to get so hung up on that that it's like an either/or. And I think we kinda do the same thing when we talk about intervention approaches, but I think what we have to just be mindful of is it's not always an either/or choice, and that oftentimes, even a child who might be presenting with more of a phonologically-based speech sound disorder could still benefit from some instruction on motor production and phonemic placement.

00:32:12 SD: And even a child who's presenting with more of a motor-based or articulatory-based speech sound disorder could still benefit from some meaningful discussion about the linguistic aspects of speech sound production. And I think that a lot of our approaches too aren't either/or, they're really on a continuum or on a dial, and they all either have more or less of this. So I think some of the nuances to speech sound disorder, just the nature of the disorder and the treatment approaches kinda gets lost in the broad strokes, I think.

00:32:48 KC: Yeah, I totally agree with that. I think that for a long time in our field, we've wanted to kind of silo these kids. You are either have this articulation-based area where disorder or it's phonologically-based. And of course, I think it's much more of a continuum than we've really recognized. And I think about some of the work, Kelly, that you've done, looking at those other underlying phonological processes, things... And I don't mean like it's speech sound errors, but what other phonological skills are these kids struggling with? What does phonological awareness look like? What does literacy acquisition look like? And what does speech perception look like? Those are all kind of these underlying phonological skills that a kid who is that fifth grader who looks like what we would might call "just attic" may have these other underlying phonological deficits, and if you look at their history like, "Oh my goodness, they've had this phonologically-based disorder since they were three," and sometimes that... I just...

00:33:50 SD: Or earlier. [chuckle]

00:33:51 KF: Yeah.

00:33:53 KC: Yes, yes. I just love looking... Thinking that as a continuum, and maybe we're moving kids along that continuum. And I think it can be confusing because as kids get older, naturally, you're probably gonna be moving towards a traditional articulation approach as they move along that continuum, but we've gotta remember those other underlying phonological skills that may still be contributing to this deficit that they have.

00:34:15 KF: That's a really important point that you just brought up there Katy, and that this is in alignment with what you said, Shari, about how the kids... The transitory nature of the disorder and how it can change over time. And so as a result of that change, sometimes the treatment approach has to change too. So maybe earlier in a child's journey, maybe if they have a really severe... What you might consider a more phonologically-based or just a lot of sounds and error, maybe something like multiple oppositions or cycles would be really appropriate for that child, but as they grow through their speech sound production abilities and maybe once they are that fifth grader, maybe now it is time to change the approach. And so I think that's another really important point or takeaway from this is to know that it's okay to change the treatment approach and you should see change in the treatment approach with the child. So not only is it good to match the approach to the child at the beginning, but to kind of check in to make sure, "Is this still the best way to treat this child?"

00:35:13 SD: Yeah.

00:35:14 KC: I think that's... Sorry. Go ahead, Shari.

00:35:16 SD: Oh go ahead. I was just gonna say, not be afraid or hesitant to move to something else. So I do think that... I think that really hearkens back to the importance of data collection. [chuckle] And so we really do need to make data-driven decisions as clinicians, and how is this working, and do we think we're really at the point now where we can move on to something else instead of really hanging on to an approach for too long when it's no longer kind of maybe getting the most bang for our buck with a particular child? So go ahead, Katy. Sorry.

00:35:46 KC: And yeah, I was just thinking right along with that, understanding, what was the approach designed to do? And so an example I'm thinking about that with is like the cycles approach. It's not meant to be a long-term... This kid is doing cycles for six years. If you look at the rationale behind the approach, the whole point of cycles is to kind of perturb their little phonological system. You're throwing these new targets at them every couple, every session, and you're changing the process you're working with on every two sessions, and it's very cyclical, and by design, you're not... The whole point isn't to get that kid to mastery of the production of those words. You're looking for, "Do I see a change in intelligibility?" So I think Shari, to your point, the importance of data collection and looking like, "Is this kid getting more intelligible? And are they producing these words with phonological processes with less frequency? And if that's the case, maybe now they're ready for a more targeted approach. Maybe they need a minimal pairs approach." And so I think that making sure that you understand, "What was this approach designed to do?" And with cycles, it's not designed to get that kid 100% intelligible.

00:36:07 KC: That's not the point. And so... And then every approach has their thing that it's supposed to do. And I think if you understand that, that makes it... I think as a clinician, gives me confidence in knowing like, "Okay, where is this kid at? And what's the approach that's gonna line up well with where this kid's at right now?"

00:37:28 KF: I think related to that, one thing that I see as something that's the most misunderstood about speech sound treatment is the importance of the relationship between target selection, so choosing the sounds you're gonna work on in therapy, and the treatment approach that you choose. I think that is one of the most misunderstood things, because I see... I've had conversations with a lot of clinicians too, and I so appreciate them sharing their experiences, their questions, but what I see happen a lot is a disconnect between those two things. So maybe they choose the cycles approach, but they're working on non-stimulable sounds, or they choose the traditional articulation approach and they're choosing complex targets, or they're choosing multiple oppositions and they only choose one or two targets and they're developmental in nature. And so the rationale between how we choose our treatment approach is just as important as how we choose the targets, and those two things go hand-in-hand.

00:38:35 KC: I agree.

00:38:36 KF: If you pick a treatment approach, you have to then know, so this is to your point Katy, of like, one, is it... What is it designed to do? And then you have to pick your target sounds for therapy in alignment with that approach in order for the approach to work the way that it's designed to.

00:38:51 KC: Right, right.

00:38:52 KF: So I think it's also helpful to, if you are at a point where you're not seeing progress with the child, is to kinda look to make sure, "Have I chosen the right sounds for this approach? Or have I chosen the right approach for this child? And have I chosen the right sounds within that approach?" I think that that connection, I'd love to see more focus on really understanding the differences between the two. Sometimes it makes a lot of sense to pick sounds that are developmentally appropriate. And I might...

00:39:20 KC: Absolutely.

00:39:22 KF: I wanna put put air quotes around that, I think. But... [chuckle] Developmentally appropriate for that child. But sometimes that's not the right way to choose targets, and sometimes they do need that complex approach. So we're choosing something that's more difficult for them that... Like my professor, Adele Miccio, would say, "If you're choosing more complex targets, sometimes you get other sounds for free." And so it's not that you're never working on those sounds, it's that you're being really strategic about which sounds you start with, so that hopefully you don't ever have to target the other sounds, they just come in through the way you're targeting the system. So...

00:39:57 KC: Well, and to that point, Kelly, I remember chatting with the clinician, she's like, I've tried the complexity approach to target selection, and my kids just like... I can't get them... We tried for five weeks to work on this complex target and we had to abandon because it wasn't working. And then my question was, "Were you keeping track of the other sounds you were hoping to get?" And she was like, "Oh, oh... Wait a minute." And so, that... Recognizing that when you're using a complex approach target selection that you may feel like you're not making progress, unless you're looking at what are these other sounds, and that's what happens, is these other sounds come along in the kid that that's the right approach to target selection for.

00:40:41 KF: I love that. Such a great point. And we've talked a few times now, about this idea of what clinicians bring to the table for us as researchers and how we would basically be paralyzed without the questions we get from clinicians and the incredible work that practicing clinicians are doing. So, with our huge respect for practicing clinicians and the fact that we have been clinicians, I have two questions for you. One is, what do you wish practicing clinicians knew about this topic? And two, related, and you can answer them in turn or one at a time. When you were a clinician, what do you wish you knew then, that you know now?

00:41:28 KC: Yeah, that's a great question. And my first thought, I was thinking back to something Shari said earlier, that at this point, I have the time to... We've spent the last three years really digging in to speech sound disorder interventions. I know a lot more now, and I think back to some of the kids that I was working with, and it's hard for me sometimes, and I think, "Ooh, I really wish I would have done this with this particular kid." And as a practicing clinician, I didn't have much time, and I was just keeping my head above water and I appreciated going to a presentation, I actually... Shari, I think this is something that you've talked about in presentations, that we've given together, and it's such great advice for me is, rather than thinking about all of the kids on my case load like, "Gosh, how am I going to get the right intervention approach for all of my kids?" That's a very overwhelming task.

00:42:27 KC: And something that we'll talk about in our talks now is, thinking about, "Okay, think of one kid right now that you're kind of feeling like, "I just keep... I feel like I'm just... Here." And think about that one kid and investigate what's an approach that might work well. So I think that's one strategy, is to choose one child, learn the approach for that kid, and once you've learned the approach, you don't forget the approach and because chances are good another kid's gonna come along, you're like, "Wait, that kid would benefit from this as well." I think on the flip side of that is go and learn about an approach, that's what... I went to a talk on complexity, I didn't know anything about it, and I think that I will recommend my cautionary tale is to not then see that approach is the right approach for all of your kids, but sometimes when you're learning about an approach... And this has happened for me as I'm learning, I'm like, Oh, and I can think of that one kid that like, "Ooh I wanna try this with this kid."

0:43:28 KC: And so I think all of that, to say, start small. None of us are going to master all of these approaches at once, we just... We can't do that, but I do think learn one approach at a time, or find the kid that you have the most questions about and learn an approach that's gonna work for that kid, and once you have that, then move to a new approach and just slowly build your tool kit, that's how I talk about it with my students, like the more tools that you have in your toolkit, pretty soon... Not every kid looks like they need the complexity approach turns out, like you have more approaches in your tool belt, you are more equipped to match what is the right approach for the right kid, so I don't know, that's just one thing I would think about. Shari, what do you think?

00:44:16 SD: Well, I was just gonna mention... So when you were talking about just learn one approach for one student. Start small. So my doctor, or mentor, Dr. Cynthia Kiarashi, used to always say, "One hard thing at a time," so she was really talking about early intervention and introducing therapy targets or progression through therapy with our young clients, but I think it also applies to us as clinicians too, so we don't have to take it all on all at once, but let's just focus on one hard thing at a time as we are working towards our professional development too. And I think for me, when I was a practicing clinician, I think I would... So I guess maybe this is still going on today, maybe people are still kind of struggling with this, but I didn't feel like I had the awareness that I certainly have now about the diversity of evidence-based speech sound disorder treatment approaches that are available to us to use for free, many of them.

00:45:19 SD: And so I think a lot of us in our training for the profession, we take one class on speech sound disorder, or if we're fortunate, we may have two, we might have one at the undergrad, one at the grad level, even though 90% or somewhere around 90% of pediatric SLPs have students with speech sound disorder, their staples on their case load, but there's so much to cover in those one or two courses that I think we do kind of lose some of the nuances and just pick up on the broad strokes, and we learn a couple of approaches that we're comfortable with, we've seen other people using and we just kind of run with those, but I think you're right, I think the more tools we have available to us that we feel comfortable using, that's really gonna help us individualize our services, more and really provide the most effective treatment for the individual students who we're working with. So I think that's something I wish I knew [chuckle] when I was practicing is I just had a better understanding of that diversity of what's available to us and what are all the tools I could be using.

00:46:33 KF: Yeah. And I think too, you mentioned the variability within the child, and I think that is probably what I... There's a lot of things, but I think that's probably [laughter] what I both wish that practicing clinicians knew now, and I wish I knew when I was actively practicing in the schools, is just the individual child, that changes a lot about the dynamics of the session. It can sometimes influence how much dosage you can get within the session, it can sometimes influence the type of words you might choose within the session, I think that the child factors and the child's language ability, the child's cognitive ability, kinda keeping those in mind and remembering that this is a little human in front of you and keeping that as the center of it, and I always kind of... I've been looking into this other theoretical approach recently called design thinking, which is used broadly to help with problem solving, and what I love about it the most is that it's a human-centered approach, and it's... You're always keeping the humans in question at the center of what the problem is, and I think a lot of times I hear and see and was most definitely guilty of this as a clinician of thinking about the sound.

00:47:50 KF: Right? So this is an R kid, this is an S kid, this kid is a lisper. So we are talking about the sound before we're talking about the child, and I think it's a really important flip if you find yourself in that mentality to focus on the kid first, because there may be a lot of things about that child that you need to address or think about in order to make progress. So if you're seeing delayed progress or kind of just hitting your head against the wall, like you mentioned, Katy, there could be a lot of other factors that are related to the child that you maybe need to address differently, and I think that's probably what I would want clinicians to be thinking about, and certainly what I could have done a better job as a clinician.

00:48:35 KC: I think that's such a great, great point. I think that one thing that I've seen a lot with these kids with speech sound disorders, motivation, I feel like we need to talk about motivation in these kids... And I think, I love this idea, Kelly, that you're talking about design thinking, is that what it was called?

00:48:53 KF: Yes.

00:48:53 KC: I wanna look more into that because I think, is that a key to these kids that don't appear to be motivated at all for therapy, and often those kids in schools are getting dismissed for lack of motivation, and I'm wondering, are we missing something? Is there something, if we... And this is purely speculation at this time. I'm really, really interested in this idea, because I've worked with those kids that have no motivation and I've used different strategies, sometimes we just need to step away from speech altogether for a minute, and just like have a conversation, I think about this kid I was telling you about who it came out like, "I just wanna be able to say my name so a girl can understand me when I'm at a dance," and once I understood that buy-in from him, then... Okay, we had this conversation, "Do you think that I can help you be able to do this?" And he was honest. He's like, "I don't know, no one's been able to do it before." And that's honest, and I'm thinking like that... But that's looking at who this kid is and not just, "This is a kid who doesn't say R." I'm just so interested, who wants to do a research study with me?

00:50:10 KF: I know.

00:50:13 SD: Me, me. And kinda made me think, Katy, I think you and I were looking into the complexity approach for a paper we were writing and we wanted to say something about this would probably work well with kids who have a little bit more kind of resilience to constructive feedback, and can sort of take that and it's not gonna break them down and they're going to keep kind of struggling and fighting, so they needed to have some grit kind of... And we wanted to mention that in some way, but it was like we really couldn't find...

00:50:44 KC: There is nothing out there!

00:50:44 KF: Any research to kinda support that, but we felt it [laughter] as clinicians, and I do think you're right, I do think there's a lot more to this complex relationship of matching the appropriate treatment approach, target selection, etcetera, to the child than just what sounds and how many are they working on? So I do think there's definitely some pieces that we could certainly fill in in terms of the research to help inform clinicians as they're trying to do their job.

00:51:21 KC: Right. Well, let's do it.

00:51:22 KF: Yeah, absolutely, absolutely.

[laughter]

00:51:28 KF: Well, you know, I think that's another thing for me too, when I think about my own clinical practice, maybe both something that I wish I knew and something that I love for clinicians to be thinking about and giving themselves some grace for... It is just how hard it is to consume research, so this idea of learning about a new treatment approach, Shari, you said early on in our discussion today, talking about repeated exposures to the complexity approach, and how the more Katy has talked about it with you, the more you've kind of understood it, and I really think that's an important message, just in general, for thinking about these new approaches, because if it doesn't feel right the first time you apply it, there's a host of reasons why that could be the case. It might not be the right approach for that kid, but it might just be that it's like, it's hard to do something new and different, it's hard to change your ways when you're used to doing one thing a certain way, it's hard to change it and it's okay.

00:52:21 KF: And so related to that, like when you're reading a new research article or even an old research article, it's hard to consume research, and so as a clinician, it would take me sometimes days to get through one research article, and it was through my training to become a researcher that I really learned how to be a better consumer of that research, but that's not something that I think is part of the training for clinicians and should it be or should it not be? That's maybe another podcast episode. But it's hard, it's time consuming and it's difficult, and I think giving yourself some grace through that process of learning something new, because it's hard, it's difficult, and you're doing it for the betterment of the children on your case load, but also for the betterment of yourself.

00:53:03 KF: And so give yourself some grace and flexibility. If it doesn't work, keep trying and it might not work the first time, but that doesn't mean that you've done something wrong, or that it's not the right approach, it just means you're busting out of your shell and trying something new, and that's a really important thing to do.

00:53:20 KC: Yeah. Oh, I think that's such a great point, Kelly. And this idea that, gosh, you try something the first time and maybe a big swing and a miss, but if you believe in the evidence that's there that says that this could be a possibility, that this could be effective, then try it again. I love that idea that it could be for a host of reasons that related to the child, related to you, related to your understanding of the approach and just give it a whirl and if it doesn't work, or maybe part of it worked and like, "Okay, well next time, I'm gonna try and do this a little bit differently." And so I think that it's just really important to have that perspective... I love that, Kelly.

00:54:04 SD: Yeah, and that kinda gets at the resiliency and the grit of the clinician.

00:54:09 KF: Yeah, totally.

00:54:12 SD: In terms of just keep trying and keep going after it, so yeah.

00:54:18 KF: Yeah, well, I think with that, I am probably going to move us into the final questions of the See Hear Speak podcast, and in honor of the host of See Hear Speak podcast, Dr. Tiffany Hogan, I'm gonna ask you the two questions that she asks all of her guests, and I'll tell you what they are first, and then you can take turns or go in order. The first one is, What are you working on right now that you're most excited about? And two is, what is your favorite children's book? And that can be either from now or from when you were a child?

00:54:53 KC: Yeah, what I'm working on right now that I'm most excited about... So I mentioned in my lab that I work with kids with speech sound disorders, I have long been interested in this idea of why, as kids are learning a new speech sound production, their ability to... Some kids are able to learn to self-monitor their own productions very quickly, and others, I feel like I'm constantly still having to tell them this is correct, is it incorrect, and so I've been interested for a long time in how are these kids perceiving speech sounds not only speech sounds of others, but also their own productions, and I've long been interested in this kind of disconnect that sometimes I think about the kids sitting in a therapy room and especially if you're working with more than one kid that maybe they're both working on the R sound and they can't tell when they themselves aren't we're doing it correctly, but they're very quick to point out when the other kid's not producing it correctly.

00:55:53 KC: I'm interested in this idea of perception, so I'm working on a study right now where we're looking at this, the relationship between how kids perceive others' speech versus their own speech, and I'm really interested ultimately to see what does this mean for intervention? Are there things that we can do to support children's ability to self-monitor their own productions, and I just... I'm really interested in this, I think it was Shari that mentioned Van Riper's traditional articulation approach that has this idea of this ability to discriminate, and that's not something that we really look at very often, and I think for a lot of reasons, we don't have a good way to assess discrimination. We don't... And those are things I'm working on in my lab right now to try and create clinically useful tools that can give us some insight into how children are able to discriminate and how that might inform intervention. So that's something I'm working on right now that I'm quite excited about.

00:56:47 SD: That's fascinating.

00:56:48 KF: That's awesome.

00:56:49 SD: Oh, I can't wait to read it.

[laughter]

00:56:52 KF: Well, I think perceptual side. Is really important. And I think it's not as well understood, I think, just in clinical application, and I do think it's probably... It's pretty right for some clinical application, but we really need the research to fill in, so that's awesome, that's great. Well, I can tell you I am most excited just to get back to in-person data collection. It's been a while for a lot of us due to Covid-19. I usually work a lot with infants and toddlers in my research, so I think it was particularly challenging to pivot to an online format, so as many parents and educators can now tell you it's really hard to meaningfully engage toddlers over Zoom.

00:57:42 KF: So with that, I do have a project that I am finally planning to conduct in-person data collection, but it will be in the fall, but I'm working on it with some colleagues in Israel, Dr. Mona Julius and Esther Adi-Japha, and it's called "Motor skill learning across toddlers with differing language skills", so for this study, we are really gonna get into testing the notion that early deficiency is associated with language development may go beyond the language domain and that young children with early language deficits are likely to show impaired procedural motor learning skills as well, so they've actually found this connection between language deficits and procedural motor learning skills with older children who are five and six years old, particularly children who had a developmental language disorder.

00:58:38 KF: So we really wanna see if that connection still kinda holds with even younger children, and if it does then potentially there's some shared neuro-developmental cause that's really kind of leading to a driving those delays in acquiring skills in both areas. So I'm really excited about it. I know it's not explicitly...

[overlapping conversation]

00:59:02 KF: But I'm really excited to get back to my roots and go back to working with some late talking toddlers again, and I'm really looking forward to it, so...

00:59:10 SD: Oh, that's fascinating. That sounds awesome.

00:59:12 KC: Yeah, it's really cool. And then my favorite... My favorite kids book? Oh my goodness. This is an impossible question. I've been thinking... I kept thinking about this one. For me, I eventually landed on... It's actually a recent exposure for me, but it's called The Wonky Donkey. Has anyone read The Wonky Donkey?

00:59:33 KF: No.

00:59:34 KC: Oh my goodness, I will share a link to a YouTube video of a hilarious reading of The Wonky Donkey. I settled on that one because it's obviously got some good phonological awareness in there, it's a hilarious read aloud, everyone will be in stitches, that's my current favorite book, but know that that was an impossible decision to commit. So I'll share the YouTube video to The Wonky Donkey reading.

1:00:01 KF: Awesome.

1:00:04 SD: Oh gosh, well, I actually have five...

[laughter]

1:00:09 SD: But I won't go into them all.

1:00:10 KC: Just one, Shari, just one.

[laughter]

1:00:13 SD: I can't, Katy, I can't. One actually book that, or a series of books that my daughter Lindy and I have been re-reading together are the Laura Ingalls Wilder, Little House on the Prairie book series, so I love those when I was a kid. I love that they were from the child's perspective, and here she is in this huge, great big expansive world and kinda growing up as I was reading the books and she's far... Laura was far from being a perfect child, so very relatable. [laughter] And then the books too, they just were so descriptive and just allowed for these really vivid mental images, which we all know really helps with comprehension, so I love them as a kid, not for those reasons, but...

1:01:02 KC: Right, good story.

1:01:03 SD: Now I've come to appreciate them more. But now as an adult and as a parent, it's really fun to go back and have that opportunity to re-read the series with my daughter, and I have actually, I'm sharing with her my actual childhood books. So some of them are literally falling apart.

1:01:16 KC: Oh, that's awesome.

1:01:18 KF: How fun.

1:01:19 SD: But we're having a good time. So we read together every night, we'll lay in her bed, and we each take turns reading a page to each other so that...

1:01:25 KF: That's so special.

1:01:27 SD: It's been really fun to revisit though. And when they were younger, we used to love The Monster at the End of This Book with Grover...

1:01:34 KC: Oh, yeah... I love that one.

1:01:35 SD: From Sesame Street. Just super interactive, super engaging, and then the Sandra Boyntono, or Boynton...

1:01:42 KC: Oh, it's Boynton, yeah.

1:01:43 SD: Boynton, thank you. The Going to Bed Book, The Pajama Time! Book, so we just love those and they had so much that really kind of fostered early development of those phonological awareness skills, and they were just so fun and interactive to read, so those are some of my faves.

1:01:58 KC: Yeah.

1:01:59 KF: Well, I'm gonna add to that list, even though no one asked...

[laughter]

1:02:06 SD: When has that ever stopped us?

[laughter]

1:02:07 KF: That's a great point, a good point... I thought it would be fun to share, like you guys have a really hard time narrowing this down, but one that I've really been liking, I try to think about how to use books in therapy a lot. And so this one is called Scribble Stones, and it's by Diane Alber. And one of the reasons I like it is because it has a lot of continent clusters, and those tend to be really tricky to treat and to generalize, and so I thought I would bring that one up because it has a lot of two and three consonant clusters within it, and so it gives a lot of opportunities to practice those within a kind of a little bit more natural environment, so related to our thoughts today on speech sound treatment, I thought that would be a good one to share.

1:02:55 KC: Yeah, absolutely, I'm gonna look that one up.

1:02:57 SD: I know, I just wrote it down. [laughter]

1:03:01 SD: And The Wonky Donkey.

1:03:02 KF: We'll have the links to all of these on the website as well. And so thank you both so much for spending this time with me, and I think...

1:03:10 KC: Thanks for the invitation.

1:03:11 KF: We're all just really grateful to Tiffany for this platform and this opportunity and we're sending lots of love and light to her as she's healing and progressing through her treatment.

1:03:18 KC: Absolutely.

1:03:19 KF: And thank you guys again so much.

1:03:22 KC: Thank you, Kelly.

1:03:24 SD: Thank you Kelly. Thank you, Tiffany.

1:03:25 KC: Thank you. Tiffany. Yeah, this was great.

1:03:27 SD: Yeah, this was really fun.

1:03:27 KF: Bye guys. Thank you.

1:03:29 KC: Bye.

1:03:35 TF: Check out www.seehearspeakpodcast.com for helpful resources associated with this podcast including, for example, the podcast transcript, research articles, and speaker bios. You can also sign up for email alerts on the website or subscribe to the podcast on Apple Podcasts or any other listening platform, so you will be the first to hear about new episodes. Thank you for listening and good luck to you, making the world a better place by helping one child at a time.