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After recovering from the haze of pure JOY that is having two consecutive days off in a row, I remembered I will be getting a new client with a disorder that 1) I have worked with only once before and 2) that I don’t know that much about from the evaluation and treatment section. All I have in my brain are the Facts that I learned about in one of my classes. And I plan to review those because I’ve slept a few hundred times since then.

It’s Better Speech and Hearing Month and I have been trying to reflect on things about what I do in my profession to make things better.  One of the most important components to our field is providing evidence-based practice, which can be a challenge because 1) there isn’t always a lot of information about the most evidence-based approach to treating a particular disorder and 2) there is so much breadth to cover in our field, unless in a job that allows specialty in one or few areas of disorders.

Where do I even begin? I love my job and what I do and I don’t mind spending a little bit of time outside work answering questions I have about evaluation and treatment of disorders, but I must have boundaries and I refuse to spend much of my free time on All the Things SLP. (Even though sometimes my perfectionist side tries to push me into SLP overdrive.)

1) First, I look through my grad school notes.  I read the Facts again. I also skim for names of specific authors and/or studies that I can then search through the ASHA website, or, try to access the articles through the library at work.

2) Search the ASHA journal database. The tricky thing is figuring out what keywords to use. Not to mention I don’t think much of the advanced search function on the ASHA journal database. (It does not allow me to use some of the awesome lit search skills I learned as an undergrad.)

3) If I have any colleagues who are familiar with the disorder, I ask for advice, or specific books, or specific articles to read.

Perfect? Probably not. Especially since I don’t have access to as many journals and academic databases as I did in grad school. But it does let me at least skim the surface of the most recent evidence available.

There is a lot of variety in speech-language pathology. One can specialize by population (adults versus pediatrics; and even pediatrics can be broken down into birth to three, early childhood, and school-age), or by disorder (although jobs that focus on even one or two disorders are more difficult to come by).

I am all over the place, I work with adults, with children, with swallowing, early childhood language, phonological disorders, aphasia, cognition…and the list goes on. A question comes to me a lot: Can I do the best I can, give the best therapy and information possible, when I see so many types of patients? (The giant thought-bubble that hangs over my head during therapy where I’m not sure where I’m going with a patient: “AM I PROVIDING EBP?”)

I am undecided on this question. I do not want to accuse therapists who do work across a variety of different orders of doing a bad job. I like to think I do a good job, although I think I can do better. (This is probably because I haven’t been SLPing for very long.) And I also don’t want to deny my colleagues one of the cool things about our field: that there’s so much to learn, so many different opportunities, and one can change the course of their career to fit their interest or lifestyle.

But when I talk to other SLPs who have been focusing their energies on one area, or a much smaller area, for a long time, their knowledge on a particular subject amazes me and makes me wish I could have that much knowledge about things. (Well, let’s get real, I would love to have that kind of knowledge about All The Things SLP, but that’s probably not possible.) I don’t know if I could ever know as much as I should about all the different disorders I see now. Maybe I don’t have enough years of practice and perspective on this to know if it is possible. Sometimes I feel like there is outside pressure for me to do All The Things SLP. Again, this might be my Type A personality projecting my stress of being a new SLP onto my daily life.

What do you think? Do you think it is better for professionals and our profession as a whole to specialize? Is it better to be a sort of SLP-of-all-trades? Does anyone have advice for reconciling a Type A personality with the expectation of doing All The Things SLP? Is it even realistic to expect everyone to specialize? Is it nice in our field that some people can specialize if they choose to, while others seek out the jobs that require therapy for a variety of individual with various disorders?

So.

The SLPing SLP’s (very own, very personal, heavily influenced by her graduate training) Definition of Articulation:

So, looking back at my definition of phonology, that…pretty much covers everything.

Basically, when I think of articulation, I think of a strictly motor or placement problem.  For example, I think of a lisp as an articulation problem. Also, if I child is still having difficulty producing sounds after around the age of five or five in a half (when phonological growth plateaus [see Shriberg & Kwiatkowski, 1994; Shriberg et al., 2994-a, -b]), I begin to see it as pretty much a motor issue.  The child has been mis-pronouncing a sound or sounds for so long that is has become a learned motor pattern.

This does affect my approach to treatment, because then I do treat initial, medial, and final position, and I do teach to sentence and/or conversation level. That’s because I am less changing a cognitive system, and more a (long-suffering) motor pattern.  Much harder to do!

(Where does that leave childhood apraxia of speech? Well, I guess that’s something to write about in the future.)

I think the importance in distinguishing articulation from phonology is how it affects treatment. Since I treat (most) my kids as having a phonology problem (how I define phonology), I only spend time teaching them the initial sound in words. (And yes, there is evidence to show that change occurs across the phonological system, by teaching certain sounds and only in initial word position, e.g., Gierut, 2001; Geirut, 1999.) It’s only when they are older and I see it as an articulation (learned motor pattern) problem, do I spend the time teaching it across positions and practicing it in sentences. Otherwise, I would feel like I’m wasting my own and my patient’s time (and insurance) by teaching all sounds, all positions, and all “levels” of production.

The SLPing SLP’s (very own, very personal, heavily influenced by her graduate training) Definition of Phonology:

As wacky as this week is going, I basically want to say: “Whatever is on those dreadful SuperDuper articulation and phonology cards is exactly what I think phonology is NOT.”

And then go read my book club book.  But then I like to think I take this blog a little more seriously than that.  So.

I agree with the ASHA that a phonological disorder is one where a child exhibits “patterns of sound error.”  However, I do not think of these patterns as the phonological processes that have been discussed and described in some areas of literature (final consonant deletion, fronting, backing, etc.; see Khan, 1982 in Language, Speech, and Hearing Services in Schools for an overview of phonological processes).

A pattern to me is when a child is omitting or substituting a sound or set of sounds consistently. While placement (e.g., backing) might be a noticeable pattern, so might whether or not the child is using manner or voice. I then examine these missing sounds and their features and use this to determine which sound or sounds to target.

Because I view phonology (and most the kids on my caseload with a sound/speech disorder) as a problem with a cognitive representation of the English sound system, rather than a strictly motor one, my approach to treatment is different from it is with articulation. If I have a child between the ages of three and four (maybe up to four and a half) with a moderate to severe phonological disorder, I will teach later developing sounds* in an attempt to change the entire sound system (because it is a system, isn’t it?  We have charts that show how place, voice a manner overlap, remember?), and I will teach only initial word position. No painstaking, long-suffering movement through syllables, medial and final positions, and phrases and sentences. Because I’m not trying to replace a learned motor pattern, I’m trying to replace a learned cognitive pattern, or, perhaps more accurately, teach the child something about the phonological pattern of English that s/he had not previously learned from her/his environment.

My definition of articulation is to come, and is much, much shorter than this one. (Yay! I can dig into my book club book!) What do you think of my definition? (That’s right! Now’s your chance to disagree with someone on the Internet!) How do you treat kids on your caseload for articulation/phonological disorders (depending on the definition you personally use)? Does your definition affect your treatment approach?

 

*The underlying theory behind choosing later developing sounds is that a more complex sound will result in generalization to less complex sounds. A good introduction to this approach to phonological treatment is by Gierut (2001) and can be found in Language, Speech, and Hearing Services in Schools.

Am I the only one who thinks there is confusion on this? While I think I have a pretty solid definition in my mind about what I mean when I say “phonology” or when I say “articulation” I get the feeling that in the field there is some general confusion or blurring of lines between the two when I talk to other clinicians. (And I’m not even adding in the confusion I see regarding childhood apraxia of speech into this.)

According to ASHA (on this page): “An articulation disorder involves problems making sounds. Sounds can be substituted, left off, added or changed.”

Also, according to ASHA (also on this page): “A phonological process disorder involves patterns of sound errors. For example, substituting all sounds made in the back of the mouth like “k” and “g” for those in the front of the mouth like “t” and “d” (e.g., saying “tup” for “cup” or “das” for “gas”).”

Well, that doesn’t really clear it up.  Let’s recap:

  • Articulation: sounds can be substituted
  • Phonology: for example, substituting all sounds made in the back of the mouth like “k” for “t”
  • Articulation: sounds can be left off
  • Phonology: final or initial consonant deletion anyone?

The slight difference between the two definition appears to be in how they start.  An articulation disorder is “problems making sounds” (but not to be confused with childhood apraxia of speech?) while a phonological disorder is “patterns of sound error.”  The articulation disorder definition sounds like a motor problem (the way your lips, tongue, mouth, whatever move to make a sound). The phonological disorder almost sounds like a cognitive representation, i.e., a child is missing a sound or set of sound representations in her/his head and thus makes consistent errors such as replacing /t/ for /k/ or /b/ for /ʃ/or /θ/.

Agree? Disagree? Do you have your own definition of articulation and phonology?  Do you not distinguish between the two at all?  How does it affect how you evaluation and/or how you treat? Why is there this confusion between the two?  Should they be differentiated in the first place?

I do separate them and it does affect how I approach treatment. But that’s a looooong discussion that I plan to break down into several posts. If anyone else wants to chime in, I’d love to hear it.  My perspective is heavily influenced (of course) by what was taught in my graduate school curriculum. I would be interested to hear what others have learned through their own graduate school curriculum and/or reading from the literature.

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