SeeHearSpeak Podcast

Introduction
(0:11) Tiffany Hogan: Welcome to Episode 3 of SeeHearSpeak Podcast. In this episode, I speak with Holly Storkel and Kelly Farquharson about their new clinical forum on speech sound disorders.
We discuss topics in that forum including those ‘new’ speech sound development norms by McLeod & Crowe, which was the most shared ASHA article in 2018. We also discuss how to determine eligibility for speech services in schools, more closely evaluating ‘artic’ only kids, and researchers and clinicians working together to advocate for best practices.
We end our conversation with Holly and Kelly describing their current most exciting projects and their favorite children’s books.
Don’t forget to check out www.seehearspeakpodcast.com to find a transcript of this podcast, links to articles and resources that we discussed, and more information about Holly and Kelly.
Thanks for listening!

Guest introduction:
(1:13) Tiffany Hogan: Welcome to the See Hear Speak podcast—the first in 2019. I will start out by having you introduce yourselves.
(1:22) Holly Storkel: I’m Holly Storkel at the University of Kansas. I’m a Professor of Speech-Language-Hearing and I’m also an Associate Dean of Academic Innovation and Student Success in the college of Global Arts and Sciences.
In terms of my research, I study why some children learn the sounds and words of the language so rapidly while others struggle, and my latest research is really looking at: what can we do to help the children who struggle?
(1:51) Kelly Farquharson: And I’m Kelly Farquharson. I’m an Associate Professor at Florida State University in the School of Communication Science and Disorders. I’m a speech-language pathologist by training and I direct the Children’s Literacy and Speech Sound—or CLASS—lab, at FSU. And the mission of the lab is to ensure that children with speech and language impairments achieve classroom success. So to that end, a lot of our work focuses on the ways in which our children, who have a variety of communication impairments, have access to services within school settings; how their teachers and their school-based SLPs are able to support them through appropriate services; and other service-related factors that might contribute to how children fundamentally receive services in the schools.
(2:36) Tiffany Hogan: Fantastic. So, this is kind of a personal podcast for me too, because I have such a great connection with both of you. So, Holly was my co-mentor at the University of Kansas on a dissertation and she started there when I started my PhD. So I got to see her develop that amazing lab, which was great and fun, and have benefitted from your mentorship throughout the years.
Kelly was my first doctoral student. I like to say it’s a little bit like Gilmore Girls, because I was a baby and only had been out—I had been out two, three years and then Kelly became my first doctoral student, so she raised me as well. So, it’s been a nice collaboration there and it’s exciting to see—just to see what you’ve done. It’s amazing.
(3:21) Kelly Farquharson: And we both talk pretty fast, so that works too, for the Gilmore Girls angle. (laughing)
(3:25) Tiffany Hogan: Absolutely. I’m not sure about the vocabulary, but hey, we can try. (laughing)

Controversies in Speech Sound Disorders
(3:32) Tiffany Hogan: Okay, so you two have an American Speech-Language-Hearing Association Perspectives forum in the special interest group one—language learning and education—coming out in a few weeks. So what is the motivation for that forum?
(3:48) Holly Storkel: I wanted to pull that together because actually, last year—2018—was kind of a bad year to be a speech sound. (laughing) There were a lot of controversies and I think it’s led a lot of us to kind of re-examine what we think about when we think about speech sound development. So one of the controversies was about the new version of the Goldman-Fristoe, the Goldman-Fristoe 3. There was a lot of chatter on Facebook groups about there being too many ‘r’ words on that particular test, and reports that students were scoring much lower, so more students were qualifying for services. We actually did a discussion of that on the Clinical Research for SLPs Facebook group to try to dig into that more. And then the latest controversy is with the McLeod and Crowe norms that were published towards the end of last year, that had sort of a similar effect of people feeling like it was new information and it caused people to really kind of question what we know about speech sound development and really how we go about diagnosing speech sound disorders and determining eligibility in the schools. So it felt like a good time to kind of go back to basics and do a forum on that, and Perspectives is really a great venue for that because you really can talk to the practicing clinicians and, I think, impact practice through having this discussion in kind of a controlled way and getting some of the issues out for everyone to think about.

“New” speech norms
(5:21) Tiffany Hogan: Fantastic. So you mentioned these speech norms, and I’ve heard them often referred to as the quote-unquote “new” speech norms. So why are people saying that these are new? I read the paper and I know that it was pulling from research that’s already been done. It was more of a meta-analysis type—so a review—pulling together some ideas, across languages, about speech development. Why was it thought of as new?
(5:49) Holly Storkel: I think it was thought of as new just because it was a new publication. So it seemed new—it’s recent, so it’s a different packaging of old things. But that re-packaging did lead to some shifting if you compare it to any single norm. So, I think most people had been using one norm source, it was their go-to set of norms, it was the one they had memorized, the one they really knew, and so then—I mean, even if you had just gone to a different, older norm source, you probably would’ve said, “Oh hey, I thought ‘r’ had this age of acquisition, but now this study is saying something different.” And so that was part of what came out of that McLeod and Crowe paper was that they had some slightly different ages for some of the sounds compared to any of the single sound norms.
(6:42) Tiffany Hogan: So when I taught speech sound disorder at the University of Arizona and then with John Bernthal in Nebraska, we would dig in quite a bit in that graduate class about how norms are established, what’s the history behind them. And it was very surprising when you really started to dig into what’s behind these norms that we take as, “This is when a child develops a certain—this is the age at which a child develops a certain sound. But when you dig into the science behind that, there are some nuances that are often lost. So how are these norms established and what’s the history behind them?
(7:16) Holly Storkel: Sure, so I think a lot of the things that people forget are all of those details, right? We’re used to seeing the chart and just thinking of it as like, that’s it, that’s the truth. But you’re right, there’s a lot of complexity behind that, so typically norm studies, the ones that we usually refer to, are ones that are a fairly large number of subjects, they’re usually cross-sectional, which means that you’re looking at kids at different ages. So the norms are not actually a look at how individual children learn sounds over time, it’s looking at groups of children at different ages. So that’s one piece. The other thing to remember too is that most of these norms use single-word production and typically children are only producing a sound in a couple of words; and so then what it means to know a sound is usually that a child produce the sound correctly in the two words that they were given for that particular sound. And then the other piece of it is, to decide what exactly is the mastery, you have to set some sort of percentage level of the percent of kids at that age who do produce that sound in that way, in that particular criteria. So one common cutoff you see is the 90% cutoff—that 90% of children produce the sound correctly that were at that particular age. So the things to keep in mind is that, one: it doesn’t actually reflect individual development, it’s looking at these kind of group benchmarks; two: it’s not a very large sample that we’re looking at and it’s narrow in terms of that single-word articulation as opposed to conversation; and that it’s kind of arbitrary, what we’re saying is needed for mastery, this 90% level. Sometimes you see a 50% level or a 75% level, so those are some of the pieces that vary across studies.
(9:22) Kelly Farquharson: I think the other piece that’s interesting about this topic to me—and Holly and I got the chance to present on some of this information at ASHA in 2018 in Boston—one piece that I think is interesting is this idea that norms were actually not established for diagnostic accuracy. The intention was never to use these norms to make a diagnosis. And so I think that’s really interesting because I think a lot of clinicians might be trained, or might be used to, using that information as, you know, this is a cut point that is, first of all, hard and fast as opposed to being arbitrary like Holly just mentioned; but also that this is the way that I’m supposed to use this information—I’m supposed to use it to make a diagnosis, when really it was just kind of looking at how these sounds develop in kids, like Holly mentioned, as opposed to really using this as a hard and fast rule for, “This child is disordered or not.”
(10:18) Tiffany Hogan: So do you think that—it seems to me that it’s probably human nature—that we look at these speech norms and we say, this feels good. Because you have parents say, “When should my child be able to make an ‘r’ sound?” And so you think to yourself, well that seems like a very straightforward question, I’m a speech and language therapist, I should be able to answer that.” When I was teaching class I would tell my students, it would be good to say to them, “50% of kids develop an ‘r’ sound by this age, based on these norms, but there’s lots of different norms,” and all the caveats that you mentioned. But that’s always a bit unsatisfying, I think. So then the parent’s like, “Well, you answered my question, but not really. What does it mean for my kid?” Right? “So what does it mean for my kid?” So tying to what you said, Kelly, about not using this for diagnostic purposes, then why—what do we learn from norms? Like, why do we even use norms? I had a student ask me that once and I thought, that’s a good question. Where do norms fit in our clinical practice?
(11:22) Holly Storkel: I think that norms are helpful at giving us some idea of what is typical but it is the case that you have to think carefully about what you’re looking at. So, in your example just now about saying, “At what age should my child be able to make ‘r’?”—that’s not the same as saying, “At what age should my child master ‘r’?” So some kids babble ‘r,’ so some kids can make ‘r’ quite early, but are they using it appropriately in every single-word of the language that requires that? No. So those are different kinds of questions. So I think the main thing in terms of using it diagnostically is that it does help us compare children to what we consider might be normative, but we do have to keep in mind some of the weaknesses of the norms, and also what they are reflecting and what they aren’t reflecting. So sort of this idea for example that 90% of the children produce the sound correctly at a certain age, that doesn’t mean that none of the children produce the sound correctly before that age. Normally kids are saying sounds and trying them out in different words, and they might not have mastered it, but they’re at least showing signs of being able to move towards mastery. Or being able to produce the sound in imitation, or some of those other things that would give us an idea that the child is starting to develop their ability to do this. So in terms of using it diagnostically it is one piece of the puzzle, but it’s not the whole puzzle. So we have to keep in mind what developmental norms tell us, and what they don’t tell us, and make sure that we fill in some of the information that they don’t tell us, through other sorts of sources.
(13:05) Kelly Farquharson: I agree, and I think another interesting point is that there are no prerequisites with respect to the order of acquisition either. And so, it’s not the case that, for instance, some of the earlier developing sounds, that we know do develop early on, in babble and in first words, typically include some stop consonants, so b, and p, and t, and d—and so we think of those as earlier developing, and we contrast those to what we think of as later developing, like ‘r’ and ‘l’ and ‘s’ and maybe ‘th,’ but it’s not the case that you need to first acquire the stop consonants—the earlier developing sounds—before you can acquire the later developing sounds. And so I think that’s another important point, that sometimes I think trips us up a bit in clinical practice, because we also might mistake that information as helpful for choosing targets for therapy. And that can be problematic too, because it doesn’t necessarily mean that we need to first work on sounds that should have developed earlier, before we can work on sounds that “should have” (I’m using air quotes) developed later—because there’s no particular hierarchy or prerequisite for order of acquisition. So a child can and should be able to produce an ‘l’ or an ‘r’ even if they can’t produce something that’s maybe typically thought of as earlier developing. So I think that can be actually one way that the norms might trip us up a bit in our clinical practice, because they make us think that there’s this specific order that we have to do our service delivery, and that often ends up taking a lot longer than a different kind of service delivery approach.
(14:45) Tiffany Hogan: Yeah, that makes a lot of sense. What struck me, too, about the paper, tying to this, is that there was no mention—at least, unless—maybe I missed it, but I didn’t see a mention of like, ‘s’ blends, for instance. So, patterns that you might expect. So you see that a child will produce an ‘s’ by a certain age, in a certain language—what does that mean for ‘s’ blends and those targets that we often see in clinical practice?
(15:13) Holly Storkel: I think maybe the reason—well, one—one reason why some of the blends didn’t come into play in the McLeod and Crowe paper—is that a lot of times the developmental norms have kind of ignored some of the clusters and things like that, or have just put that together with ‘s’ or put it together with ‘r’ as opposed to pulling them out separately. So that’s kind of one issue, is how well our norms have considered the clusters. And some of that comes from, usually when you do these norms, you don’t want the kids to have to do like two hours of testing, so you kind of have to focus in on what you really need. And so sometimes I think the blends have gotten chopped off in favor of the singletons. The other reason, though, in the McLeod and Crowe paper, I think, that that might have been further part of the issue, is that their emphasis was on looking at development across languages and blends are not common across languages. So English is kind of crazy on the blends. We have all kinds of clusters. You can put pretty much anything together. But many other languages don’t have blends at all, or have very restricted kinds of blends, so that might’ve been another reason why that wasn’t highlighted as well. But certainly in terms of our clinical practice, having developmental norms for clusters can be a really important piece to thinking about what children ought to be able to do at particular ages.

Speech norms across languages
(16:42) Tiffany Hogan: You know, that might address an observation I made about the paper. And I found it interesting that in the paper, with a focus, really, on speech sounds across languages, it was interesting that some of the sound characteristics such as manner, really predicted how early sounds were developed in these—across languages—but some didn’t! So, for example, I noticed that English ‘r’ was categorized as late developing, but in Japanese it was middle developing, but it was reverse for the ‘z’ sound. So it seems interesting that there’s this idea of universal norms that was discussed in this paper, but it doesn’t always apply. And maybe that’s because of ambient language that they’re hearing, maybe it is some of these blends too—if ‘r’s are being tested in blends, I could see where that might be a little later in another language that might not have as many ‘r’ blends. I guess I was wondering if you could speak to that aspect of the paper—this idea of universal norms.
(17:45) Holly Storkel: Sure. I think we do have this idea that there are some characteristics that tend to be similar across languages, and manner would be one that has been claimed, that there are simpler or less complex manner categories, and more complex, and that that tends to be similar across languages, so you tend to get kind of similar groupings of sounds in terms of the developmental progression across languages. But it’s also clear that there are influences from everything else that’s going on, so there are some kind of older papers—Jan Edwards was one of the people who looked at this a little bit, and looked, at for example, frequency of occurrence of a sound in a language. And the more you hear a sound or the more it’s used in your language, that does tend to have at least some impact on when it’s acquired. So that’s a place where you might get that kind of small adjustment of ‘r’ being earlier or later. And then as you indicated too, there might be other ways that the sound operates in the phonological system that then might push your acquisition earlier or later depending on how else it works. And we see that in other aspects of language, too, so in grammar, sometimes you’ll see certain grammar features being learned earlier or later because it’s potentially a little bit simpler in that particular grammar or a little bit more difficult in that particular grammar, depending on what else is going on in the language.

Speech norms in clinical practice
(19:21) Tiffany Hogan: So you noted in your ASHA talk last year, some take-home messages when speech-pathologists are considering speech norms in their clinical practice. So with all of these caveats in mind, how should speech norms be used in clinical practice?
(19:39) Holly Storkel: Well I think we don’t want to throw the norms out, I think the norms do have value, so that’s not the message—it’s not, “Get rid of them,” but to just really think about what they’re telling you. And so I think the key things are that norms can’t be reduced to a single age or a single cut point. We don’t know the diagnostic accuracy of norms, and this is something Kelly hinted at—that norms weren’t really intended to sort children into those who are disordered and those who are normal. So we haven’t done that kind of work that you see for example on standardized tests, where you actually look at how well different scores on the test can accurately sort children in to those who have disorders and those who don’t have disorders. So I think we should think of the norms more as guidance, for one thing, and if we can look at development in a broader sense than just a single age, that’s helpful. So one of the things I show in my article in the forum is how you can look at the 75% age of acquisition, the 90% age of acquisition; and actually, in the Smitt norms, all of the data are there. So you can look up the percentage of children at a particular age who are producing a sound correctly. And that’s another good piece of information so that you can get that broader sense of what is normal. And then the second piece is that you cannot use norms just by themselves. Again, it’s one piece of the puzzle but it’s not the whole thing. So you always need multiple measures. And that’s another factor that’s illustrated in my article in the forum, where I show what a standardized test score might be for a child who has a particular pattern. And the thing to keep in mind is: what is that standardized test score telling you? Well, it’s telling you something about the total number of errors that the child is making and how that compares to their peers. And then you can look at the norms and sort of see—are the sounds that the child’s making errors on—are those ones that are typical at their age? And you have to kind of be able to put both of those things together. Because if you look at just the norms by themselves, you aren’t getting that sense of, “Is this overall number of errors age-appropriate or not?”
(22:04) Tiffany Hogan: So this seems very reasoned to me. Makes a lot of sense. So why are these topics controversial? So you said that right in the beginning that there was some controversy about these norms, there’s controversy about the tests you used, why?
(22:19) Kelly Farquharson: Well, I have one thought, and Holly and I have talked about this a little bit too—but I think there’s something to be said for what you hinted at earlier, Tiffany, which is, it being slightly unsatisfying to not get a direct answer about, “When should my child be able to do this?” And we do—you know, parents really rely on milestones to make sure that they’re taking action if their child needs support in some area of development. So whether it’s when should they start eating certain foods, and when should they start walking, and when should they start talking? Those milestones are important, and so it’s satisfying to know here’s when it should happen and your child is doing it, and I think as clinicians, then, it’s also satisfying to say, “This is when your child should be able to do this,” and so as a result, it’s still normal that they’re not doing it, so I’m not going to provide services. And so in some ways I think it’s controversial because it’s been something that a lot of clinicians have come to understand as a reliable metric of determining who might receive services or not. And the fact that it might not be as reliable as they thought it was—and that can be disconcerting. And I think there’s also—importantly here, too, this is no one’s fault, this is not anything anybody has done wrong along the way, and I’m not quite sure what the origin of the heavy reliance on the norms—where that came from—but it doesn’t mean that a clinician has been doing it wrong if they’ve been adhering to the norms quite strictly. I think now it’s important that we use this as an opportunity to expand the way we think about speech sound development, and kind of, as Holly said, use the norms, but for what they’re intended and for what they tell us, as opposed to using it for the only piece of data that we’re considering. And so I think that’s part of the controversy is it’s uncomfortable, it’s kind of bucking the trend, it’s not what we have typically been doing, so it might make us feel like we’ve been doing something wrong as clinicians, or it might make us feel like, “Well gee, if I can’t rely on that, then how do I know?” And that can feel a little uncomfortable.
(24:30) Tiffany Hogan: Is it also a situation that it could feel like the floodgates are going to open? So I’ve seen on the clinical forums—it’s been a long time since I’ve had clinical practice—but I do know caseloads are an issue, so if you’ve been holding to speech norms, and standards that say, “I’m not going to address ‘r’ till eight,” for instance—and now you have these quote-unquote “new” speech norms which are highlighting the variability, and saying “You know, maybe it’s better to look at this as early as five or six.” In particular in the English language, they might think, like, “Ugh, now I’ve got to treat all these extra kids. How does this affect my caseload?” So what do you say to that concern?
(25:08) Holly Storkel: Yeah. I actually—as Kelly was talking—was making a note to address that because I think that is a huge reason for the reaction—that it’s the impact that it has on clinical practice and the suggestion that children potentially need to be picked up earlier and I think you’re absolutely right. The caseload sizes are kind of crazy, and that’s not even having to do with speech sound disorders. That’s just in general. I think it’s really a crisis in our field that the caseloads are so high, that it really does impact our clinical practice. So to the first point, I actually do think we probably should be picking up kids earlier for speech sound disorders, and I don’t think we have the clinical evidence yet to fully support that in a strong way. But if you look at more what we know about normal development, the window for learning phonology closes, and it closes early. And we can figure that out just by looking at our second language learners—our second language learners who are trying to pick up the phonology of the language later in life, we see that they struggle a lot with pronunciation of certain sounds, and that it’s really difficult for them to figure out the phonology of a new language. And other studies show us that. We can also look at the infant research and see how infants are born with the ability to make all of the distinctions in all of the languages and hear those differences, but by six months their listening and hearing starts to narrow down to just the sounds that are used in their language. So we see this narrowing of the ability to learn phonology, which suggests that if we worked with children earlier and picked them up earlier, they might be at a point where their phonological skills are more flexible, and that they would actually make change more quickly and with less therapy time. So I think the idea of picking up kids earlier is a good one, but it is difficult to implement because of the caseloads. So I think one of the important things to talk about is how we can, as a group, support our clinicians in advocating for reasonable caseloads, because it really affects all aspects of our practice. And I understand where those clinicians are coming from in terms of, you know, “I can’t even pick up the kids who absolutely do qualify based on what I thought was true, and now if I’ve got to pick up even more even earlier, there’s no place to put those kids, and that’s really a problem.”
(27:45) Kelly Farquharson: Yeah, I agree, and I think there are some other interesting pieces there—I agree with Holly’s points on, some of our research needs to really start tilting towards making sure that we’re examining how some of the recommendations from research can be implemented in a school-based setting. It’s a very challenging setting. There’s a lot of moving parts, caseload being one of the biggest issues, but there’s a lot of other moving parts there that make school-based practice really challenging. And so our research really needs to start considering how we can create ecologically valid recommendations that can be implemented in the schools, and so that SLPs can consider the research implications. Because I think right now it’s really challenging to do that, because I think there’s so many other things happening, caseload being part of that; paperwork being another part of it; a lot of other SLPs might be itinerant, meaning that they have a multiple schools that they provide services to, so they’re not just in one building, they’re traveling throughout the day. And then that doesn’t even take into account what their caseload—not just headcount of the caseload—but really the workload. So they might have a caseload of fifty kids who are in the general education classroom for the majority of the day with the exception of once or twice a week, speech therapy, is a very different caseload than fifty kids who are in inclusive, self-contained classrooms that are nonverbal, or have complex communication disorders, perhaps use augmentative and alternative communication, perhaps have a variety of medically complex disorders. That’s a different caseload, and so those headcounts aren’t synonymous. We can’t say that fifty kids on one caseload looks like fifty kids on another caseload, and so there’s a lot we need to consider there to make sure that we’re making suggestions that SLPs can take seriously.

Advocacy
(29:39) Tiffany Hogan: What are some of the ideas that you can say—some tips for how to make this manageable on your caseloads? I know in the Perspectives forum, you do discuss some of those ideas, and also you did in your ASHA talk as well.
(29:56) Kelly Farquharson: I’m pretty big on advocacy, and a lot of my work has also looked at some of these bigger issues, like SLPs’ job satisfaction, and their self-efficacy, and how their caseload size contributes to the kinds of decisions that they make. And so I think a lot of schools—one thing we have going for us in terms of advocacy—is that a lot of schools (the administration) are data-driven. They want to be able to talk about the science that their education is based on, and they want to be able to think about using research-based methods in their classrooms. And so then one way to have a conversation with them about these issues is to use the research and say, “These are some other ways we can use the literature to support practice in the schools, beyond what we’re teaching the kids but also to ensure that we’re creating a work environment that’s conducive to the services that these children need.” And so, for instance, we know a lot about job satisfaction with respect to caseload size. And so SLPs—not surprisingly—with smaller caseloads report higher job satisfaction. That’s empirically supported in the literature so we can share that information with our administrators. There’s also been work looking at what actually makes a caseload feel manageable, and it does include the size of the caseload, but it also includes the SLP’s years of experience as well as how collaborative their environments are in which they’re working. And so administrators, and teachers, building principles, have a big job to do to make sure that SLPs are working in an environment that feels supportive and collaborative, feels that their voice is heard, feels that they’re making a contribution to the team. And then that years of experience piece—you only gain those years of experience if you stay at that school, if you stay in that practice, and you don’t get burnt out. And so a lot of school administrators are interested in not just recruitment of speech pathologists but retention. And so that retention piece, we know, is really important because the more years of experience you have, the more you feel as a clinician like your caseload might be manageable. At least—this is empirical data, there is of course going to be exceptions to this. And then some other work has actually shown how important job satisfaction is to the quality of therapy that speech pathologists implement. And so that’s another really big piece too. If we’re conducting better therapy that’s of higher quality because we’re happier in our jobs, we can presume, then, children will be off of our caseloads sooner and we’ll be able to use our resources more efficiently. And so these are all points that are empirically supported, that are available in the literature, that I think we can use as talking points to school administrators to make sure that we’re not just complaining about our work setting, and about how overwhelmed we are, but we’re actually using the literature to say, “Here’s why it’s important that we improve this practice.”
(32:47) Holly Storkel: I would add to that, too, that I think we need to organize as a group. Individual clinicians can do some of this, but at the same time we need to be sensitive that individual clinicians are overwhelmed with their caseloads, so adding on the advocacy piece is just another piece to try to add on. And so I think this is something that we need to be thinking about among probably our state associations—of how our state associations can craft this message and bring this message more broadly for all SLPs to all employers about, really, the impact of high caseloads—and try to make that argument as a group rather than forcing each individual SLP to make that argument. And I think especially in the schools, school administrators don’t have a good grasp of what SLPs do, and so that’s a real barrier. I think the administrators look at SLPs and think, “You should be able to see as many kids as a classroom teacher,” not understanding the types of services we provide, and the kind of intensity, and many of the other things that Kelly just ran through. So it’s a long argument for an individual SLP to have to kind of lay all of the groundwork of helping others understand what our job is and what we need to be able to do it well. So if we could craft that message at a more organizational level, and kind of have one voice on that particular issue, I think that would really help us get some movement here.
(34:25) Tiffany Hogan: So I’ve been involved in some advocacy for dyslexia, for children with developmental language disorders—and the difference between those two that struck me the most is that when you have dyslexia, there’s the International Dyslexia Association, there’s tons of information out there—a lot of misinformation—but there’s tons of information, it’s a household name, people know what that is. Developmental language disorder, there’s a movement now to create more awareness, and a website, DLDandme.org, educating parents, professionals, giving that information for advocacy. But I don’t see that same thing happening with speech sound disorder. I think it needs to be the next group that we focus on, and it can happen in parallel with these other groups. I want, Kelly, for you to talk about the Perspectives paper that you wrote, because you hit on something that I hear often, and that is, “Well, the child’s just artic. It’s just speech sound disorder.” So even in clinical practice, these are the kids that are seen first by training clinicians, because it’s thought of as, “That’s easier. That’s easier to deal with.” But what I think is missed—and a lot of it’s highlighted in the work we’ve done, Kelly, and many others—that speech sound disorder is not just artic and that there’s other skills that are developing at the same time and that speech sound can be foundational for these critical skills. Can you tell us a little bit more about that?
(35:58) Kelly Farquharson: Yeah. I think that’s a really good point, and I agree. There’s a lot more to the story with these kids. And thanks for giving me the chance to talk about this, because this is something I’m really passionate about, and thanks again to Holly for the leadership on the forum that’s coming out in SIG One Perspectives. All the authors in the articles in that forum responded to some cases that Holly provided us, and so we were able to kind of create, at least I hope, a unified message with respect to what this might look like from a variety of perspectives. And so the way that I think about these kids is speech sound production is always a motor act, and a linguistic act, and so I think we try really hard to put speech sound production into either articulation or phonology, and we really want desperately for it to stick, kind of, in that box. So we can say “This is an articulation kid so I don’t have to provide services,” or, “It’s different.” Or say, “This is a child with a phonological disorder and it looks like this and sounds like this. It’s different.” And really they exist along a spectrum and it’s quite the same thing. And so I think we’ve spent a lot of time trying to separate two constructs (articulation and phonology) that are ultimately the same thing, that include both a motor act and a linguistic, meaningful act. And so, in doing so, I think we’ve possibly done a disservice to some of these children, by saying things like, “It’s just artic,” meaning, “Your communication impairment isn’t as important as somebody else’s.” And I think that’s really unfair to these children. Related to that, we know a lot more now about some of the underpinnings of that inability to produce a speech sound. So perhaps it is more rooted in a motor deficit, that’s a possibility for some kids. But a lot of kids, it’s kind of grounded in even maybe a mild phonological deficit. And so their speech sound errors might not necessarily present in the form of what we think of as a phonological pattern, per se, but there still might be some underlying weaknesses related to their knowledge of the phonological system. We see that manifest in their ability to use and understand or participate in phonological awareness tasks, like rhyming and blending and deleting, we see this manifest as issues with decoding, and for a lot of kids we see this as issues with spelling. And so, in a lot of very interesting examples, we see—and I highlight one of these examples in my article in the Perspectives piece—a very interesting example of a direct use of a speech sound error in spelling. So there’s an example of a boy that I highlight who uses a an ‘f’ instead of a ‘th’ in his speech sound production, so something like ‘fum’ instead of ‘thumb.’ It’s probably hard to hear that, but, an ‘f’ instead of a ‘th.’ And in a spelling measure we gave him in a study in my lab, he used the letter ‘f’ at the beginning of a bunch of words that should have started with the grapheme ‘th.’ And so he was showing that he’s got this fundamental disconnect between how his speech is produced and how that connects to the letters, how the phonological system is mapping onto the orthographic system. And so that’s really interesting to me because it’s showing how complex this process is. I think that particular child is one who, by all accounts, most speech pathologists might say, “He’s just artic. It’s an ‘f’ for ‘th’ substitution, this is typically developing, it’ll go away.” But I think what we need to do is look a little bit deeper, and say, “Well, let’s just take a look for this kid, is this impacting other areas in which this child is using phonology?” And so we can look at phonological awareness, and then depending on the child’s age we can look at their decoding, word reading skills, and we can look at their spelling skills. And that’s all dependent on their age, but that can give us some really robust information to help us figure out: is it appropriate for us to be saying, “This is a mild issue, it is affecting one sound, and it doesn’t really seem to be impacting other areas in which this child is using phonology.” Or should we be saying, “Actually it looks like even though it’s just one sound, there’s a lot happening here that’s impacting other areas of language that use phonology.” And that can start to bleed into word learning too. Our ability to learn new words relies heavily on our phonological use and our understanding. And so that’s, I think, one piece of it that is really important for us to consider for these kids—is that a single sound error can still be detrimental to intelligibility, to literacy, to self-confidence, to the perception that others have of you. There’s some interesting and unfortunate research looking at how teachers perceive children who have even one sound in error. They perceive them as having lower cognitive ability even though their issue is one single sound. The production of one single sound. And so that’s really powerful to know that that can change the way that someone views you. And so we need to consider it just as important as any other communication impairment.

Clinician-researcher connections
(41:12) Tiffany Hogan: I think that work’s so critical too because you often hear—when you’re working in schools, clinicians will say, “Well, you have to show a functional educational deficit.” And that can be difficult with speech sound disorder. The research you’re highlighting is really critical to show that it does have a functional impact on the way that you’re perceived and also on your educational outcomes such as reading and spelling and language skills. So that’s, I think, a really important aspect. Thank you for highlighting that work. The last thing I’ll discuss here is going back into the advocacy and what we can do, as a field, with speech sound disorders. And I wondered if you could talk a bit about—as kind of a final note in this vein—what do you hope clinicians take from the clinical forum in Perspectives? How do you hope that it impacts their advocacy?
(42:16) Kelly Farquharson: I’ll start. I think one thing is that I view us all on the same team. And so I hope that there continues to be improved conversations between clinicians and researchers, and I hope that this forum, among some others that have come out recently—including yours, Tiffany, in LSHSS, on dyslexia—I think some of these forums, I hope, highlight how desperately researchers want to help clinicians, and how we view the importance of clinicians in this conversation. And so I think that’s one big piece of it that’s probably not explicitly obvious. But I think that’s an important takeaway, is that we do this work because we care a lot about these kids too, and our actions in the research realm are two-pronged; and one is to help the children that we all are interested in helping support, but the other is to help the clinicians. And so I hope these papers are viewed as useful ways to think about this disorder, which truly is complex. You know, I think we want to think of this as—and maybe it’s not as medically complex or technologically complex as some other disorders we may work with or treat—but it’s still, I think—there’s not an SLP out there who hasn’t at some point kind of banged her head against the wall saying, “How am I going to get this kid to make an ‘r’ sound?” It’s challenging! It’s a complex disorder. It’s complex to treat, and like Holly said, the sooner we start the better, as a result of that. And so I’m hoping that clinicians who read these articles really kind of feel our passion for this population and that this is another way to kind of keep this conversation open with ways that we can support clinical practice.
(44:06) Holly Storkel: I would kind of add to that—I hope that they come away with an idea about best practice and how to incorporate some of this newer information into their practice and aren’t confused or in a muddle, which is kind of what we’ve been seeing in some of the Facebook discussions, of not really knowing how to parse this or not really knowing what to do with it. So I hope that comes through. But I also hope that just as Kelly was describing, I hope that people come away with an understanding of the need to serve this population. And I think the way the conversation has been, has been more like, “This is the time I have on my caseload, and this doesn’t fit,” whereas it should be something more like, “This is what needs to be on my caseload, and this is how we need to get there.” So I think as a field we’ve sometimes just been satisfied with what we’ve been given, and we shouldn’t be satisfied by what we’ve been given. We need to fight for what we actually need. And so I hope that we come away with that feeling of, “This is a time in society where we need to march”—do these kinds of things and kind of speak out on social issues. And I think we need that in our field, to say: thirty minutes twice a week, and this number of kids, and whatever, that’s what we’re given, but that’s maybe not the optimal things that we need, maybe not the optimal environment that we need to really serve this population well. And so we need to be thinking about: how do we marshal our forces, and again, how do we work together to marshal our forces and say, “This is really what we need to do this well, and here’s the impact of being able to do it well.” And so Kelly made a lot of really good arguments along those lines. But I hope that people come away with that feeling of, “We need to work together, and we need to really fight for this particular population and make sure that they get the services that they need, along with the other populations that we serve as well.” So it’s not trying to take away from one to give to another, but really saying to the people who make these decisions about how many SLPs there are in schools and that type of thing, this is what we really need to be able to do this job well.
(46:18) Tiffany Hogan: That’s fantastic. And I think it’s just so empowering for clinicians to hear this, and thinking about the connections between research and practice—that we’re all on the same page working together towards a common good. And I think that what struck me about this population too, in studying multiple populations of children with communication disorders, often time the speech pathologist is the one to advocate for these children. When I worked with children with dyslexia, you have the teacher, the reading specialist, the special educator, the speech pathologist. And language disorders, similar. Lots of disorders have multiple team approaches, but with children with speech sound disorder, it’s not that uncommon for the speech pathologist to be the one person, especially early on, that has to advocate for that child, and make sure that they do have the educational support while being in socioemotional development. And so this is so important to shine the light on this important topic, which I think can be overlooked at times. Okay, I’m going to turn, as we wrap up, to a different topic. But it could be in the same vein. I want to know what you’re working on now that you’re most excited about.

Current research
(47:30) Holly Storkel: I have a grant from NIH where we’re doing a preliminary clinical trial of interactive book reading. And so this is something I’m sure clinicians are familiar with: an adult reads a book to a child, and then you attempt to teach them something within the context of this book. And the something that I’m working on is how to teach new words to children who have developmental language disorders. So we’ve been working on this project for five years and we’ve got another five years that we’re going to be working on it. We’ve established the intensity of the treatment, and some of the issues with what the format should look like. But what we’re seeing, really, is that not all children benefit from it. So one thing we’re trying to understand is, who does this work for, who does it not work for? And the other thing that we’re seeing is we can get good learning during the treatment, but the kids don’t actually remember the words very well once you pull them off of active treatment. So we’re working on doing more active testing and more engagement in the book reading from the child’s point of view, to see how that will boost their learning and hopefully their long-term retention of words.
(48:45) Tiffany Hogan: Fantastic.
(48:50) Kelly Farquharson: Well, just starting a new position at Florida State, I’m excited about a lot of things that I have going. But I’ll focus on one particular project in which we’re really trying to get to a way to fully examine how speech sound production errors impact spelling. And so towards that end, I’ve been working with a researcher in the School of Ed here at Florida State, Nicole Patton Terry, and we’re developing a coding scheme that’s going to allow us to look at the spelling patterns of children who have speech sound disorders, and see if we can figure out the kinds of errors that they make, and how related those errors are to their speech sound error patterns, and their spelling. So I’m really excited about that because I think that’s going to give us some interesting information beyond what we already know about spelling with respect to the kinds of phonological, orthographic, and maybe morphemic errors that children might make. Now we’re going to also add the layer of looking at their speech sound production and then seeing the ways in which that is being manifested in their spelling, if at all. And I think that will be useful information—for us to really think about the connections between speech sound production and literacy, including spelling but also really thinking more broadly about decoding and phonological awareness, and those types of skills. So I think that’s what I’m most excited about right now.

Favorite children’s books
(50:10) Tiffany Hogan: Awesome. Well, thank you for sharing that. We’ll keep it on the horizon, for sure. We’ll be looking at that work. The last question I always ask guests is, “What is your favorite children’s book?” And this can be a book that you read as a child or one that you’re loving right now.
(50:29) Holly Storkel: My son is actually twelve and in middle school, and so it’s interesting because now he’s reading some of the things that I remember reading and kind of discovering some of the books that I liked. And he’s discovering them on his own, like, I’m not—terrible parent, I guess—because I’m not giving him a book. But one thing that has been kind of fun to revisit is he’s found Judy Blume. And I loved reading all the Judy Blume books. It was like “Oh, I’ve totally forgotten about these books.” But how much I just loved those, that was, like, an author that I read all the time myself in middle school, and just devoured all of her books. So that’s been kind of fun to talk with him about what he’s reading. And he loves them just as much. Which—that’s also interesting that they’re as appealing to boys as they are to girls.
(51:16) Kelly Farquharson: Yeah.
(51:17) Tiffany Hogan: Across the generations. I mean, that’s very cool.
(51:22) Kelly Farquharson: This is a hard question for me because I love children’s books. So I’m going to answer it in two ways, which is probably not exactly what you’re looking for. But I have been loving the elephant and piggy books, so there’s a character—and the author is Mo Willems—and there’s an elephant and a piggy, and they have these fantastic conversations. And one of the things that I love about the books is they use a lot of speech bubbles, which I think are really helpful when we’re reading to kids and talking about whose perspective is it, and who’s currently speaking. And he also plays with font size and font type a lot, too. And so when one of the characters is really trying to make a point, there might be a two-page spread that is just comprised of an entire speech bubble and huge font. And I think that’s really a fun way to show the importance of print when we’re reading. But I think my all-time favorite book is, as you probably remember, Dr. Seuss’s The Sneetches. And I just love that book, I think it’s such a fun story. It also has a nice social piece about inclusion and equality, but there’s also a lot of ‘s’ blends in that book, and so it’s a fun one to use in therapy because there’s a lot of ways to target correct ‘s’ production and ‘s’ blend production. And I just really love Dr. Seuss, so I think that ultimately, The Sneetches is my favorite book.
(52:40) Tiffany Hogan: Oh, that’s awesome. That’s fantastic. Well, thank you so much for taking the time today to talk about the forum and some of these important issues for clinicians. Thank you.
(52:50) Kelly Farquharson: Thank you so much.
(52:52) Holly Storkel: Thank you.
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Episode 3 Closing
(52:55) Tiffany Hogan: Check out www.seehearspeakpodcast.com for helpful resources associated with this podcast, including, for example, the podcast transcript, open access articles, and speaker bios. Thank you for listening, and good luck to you, making the world a better place by helping one child at a time.