#149: Assessing Speech Sound Disorders: Making Recommendations

Marisha : Hello there and welcome to the SLP Now podcast, where we share practical therapy tips and ideas for busy speech language pathologists. Grab your favorite beverage and sit back as we dive into this week's episode.

Welcome to the SLP Now podcast. We are continuing the series with Lindsey from Speechy Things. And today we are wrapping up this month long series and we are going to talk about making recommendations. So at this point we would've done our case history, oral mech exam, a speech sample, maybe some formal assessment. We talked about perception tasks and trial therapy, all sorts of good stuff. But Lindsay, can you help us walk through, okay, so we have all of this information, what are some of our next steps

Lindsey: In terms of making recommendations, either recommend or not recommend therapy, maybe recommend a reassessment in however many months. You'll recommend how many times a week for how many minutes. Yada, yada yada. But something I feel like is missed is referrals, outside referrals. I feel like this comes with experience and this comes the more we collaborate with other professionals and work as a part of a care team instead of it just being between us and the family and that comes with time and experience and a lot of effort. We're so busy. I can't even fathom working in a school and the caseloads they deal with and the paperwork they deal with because even in a clinic, it was hard for me to find time to do this stuff. But referring sometimes back to a pediatrician or getting counseling involved if that's needed or PT, OT, a dentist, ENT, GI, Nutrition, depending on what's going on.

I feel like for speech sound disorders, some of those aren't as applicable, but I just want to encourage people to, if in doubt, refer. And do your best throughout the assessment, I mean, starting with the case history and then all the way through and keeping your eyes open. By the way, I feel like it's easy for us to focus so much on the sound and not watch what's in front of us. Looking at posture, looking at are they fidgeting a lot? Not that that's a bad thing, but it might tell you something about sensory needs. I just feel like it's easy for us to get so focused on our piece of this puzzle that we forget the kid might benefit from help in another discipline. And it's just, it's hard. Oh man, our jobs are hard, Marisha. There's a lot.

Marisha: There is a lot.

Lindsey: There is a lot going on all the time.

Marisha: Yeah. But that's a really helpful overview of people that we could refer to. And if we're seeing something, even if we don't know what it is, be like, "Oh okay. Would any of these people be able to help?"

Lindsey: Yes.

Marisha: That should be a whole other podcast episode. Not even a podcast episode, it should be a whole day seminar essentially.

Lindsey: I know.

Marisha: Just like this podcast episode could have been.

Lindsey: Yeah.

Marisha: There's so much stuff. What would you recommend? So I'm sure some school based SLPs are like, "But I'm in the schools. What does this look like?" Do you have any thoughts around navigating that?

Lindsey: I do have thoughts and I can't claim any of them. I did a clinical placement in grad school in the schools for one semester and that was it. So this is coming from my awesome Instagram follower community because I have spoken about this before on Instagram and in a clinic I don't feel like it is so much easier for me to just refer left and right whatever I think they might need, even though that could be a sensitive conversation with a family and that's tricky. But in a school I got a whole bunch of responses from therapists on how they might approach a referral. And the common threads mostly was putting it back on the pediatrician.

One person did say... But y'all please don't go doing this in the school and then getting in trouble. Please talk to your supervisors or whoever before you even utter any of the words that are about to come out of my mouth. Do not email me telling me you've got in trouble. Okay? So do your homework. Anyway, this gives you some ideas that might work.

So one person said that they used the phrase, "If it were my child, I would consider..." I feel like that's a little bit risky. I don't know. An overwhelming amount of responses from people recommended that they suggest the parent ask the pediatrician about it. And so more specifics within that would be just the actual wording to suggest that they bring up XYZ concern at the next pediatrician appointment. One person also mentioned just stating point blank, if they decide to do anything outside of the school, it's up to them and it's at their expense. Another recommendation, the specific wording I'm going to read it because I feel like it's a very careful quote, so I don't want to do it wrong. They said, "If insurance and finances allow, you can always share your IEP findings with your pediatrician and see what medical options there are."

So I feel like the keys there would be sharing the IEP, which I think is very helpful because I don't know if parents always realize that they can... That paperwork is theirs to do whatever they want with. Whether it's the IEP, whether it's an evaluation from a clinic, that's your child's medical information and you can mail it to anyone you want, broadcast is on the internet, whatever you want to do. And it can be so helpful to share that with other professionals and I think the idea of actually bringing that to the doctor and then hopefully this pediatrician is fantastic and can kind of decipher what they're looking at and knows where they might need to go. But anyway, I thought those were really helpful suggestions.

Marisha: Yeah, I love that. I'm really glad you looked into that and put that together. Yeah, I love it. This is not a goals episode at all, but I'm just curious, and we kind of touched on this as we went, you mentioned a couple times the case history is our gold. It's very critical as we move forward and I'm trying to find the best way to navigate this. So with the perception tasks, for example, maybe it'd be best just to go through a couple cause it's hard to give suggestions and ideas if we're super, super broad. So maybe we can start with some more specifics.

Let's say a student really struggles with perception tasks and in the speech sample in the formal assessment, we find that they have, they're gliding all of their sounds. And then with trial therapy, we are trying to elicit an R, but we aren't able to elicit an R. So how would that influence the goals that you write versus if they rock their perception tasks and they were stimulable? And I know this is hard because we're not seeing an actual kid. Do you ever write goals for perception?

Lindsey: I do. And you know what? That is something that a lot, I feel like I saw several times in the summit, SLP Summit Q&A that we just did a couple months ago. I feel like it's something maybe people just aren't doing. And I know I never used to do it, so I totally get that. It's just as I'm learning more and more and more, I see how important it is. So I think it's totally fine to write goals for perception tasks because I think it's one of the beautiful things about therapy. That's what makes us so skilled and that's what makes us clinicians, not technicians. We can break things down, especially through years of experience and all this clinical knowledge that we have. We can break things down into the tiniest little baby steps to get where we need to go and we can see all of the foundational skills and scaffold the heck out of it so that we can support the student all the way to getting out of our speech room forever.

And I think perception tasks are one of those little building blocks that are a foundational skill that is worth writing a goal for if it's something that they struggle with. And whether or not you do perception tasks before working on elicitation, I'm seeing conflicting advice about that. I tend to do perception tasks first or not necessarily first, but I don't think you have to master one thing before you move to another. We're always working on multiple aspects of whatever's going on.

Marisha: Yeah, this is where our clinical judgment comes in. It's not a black and white answer and there's a lot of gray in here. I really wanted to touch on this because I think it is a helpful, as a CF, I had a handful of our kiddos talk about R because that's what you're so good at.

Lindsey: I can't get out of my head. I'm trying so hard to make it more general than that.

Marisha: Now, I love it though. Some kids, it was really easy to elicit the R and we just flew through therapy, but there were some kids where, I don't even want to admit how long we spent trying to elicit an R, and that's all I was doing. And I found ways to make it fun enough, I think. But who knows, if I had been using some of those perception tasks, it could have decreased the frustration and maybe we would've seen more progress because maybe they just needed that. And I can't explain it well either, but maybe there is something like they needed that representation in their brain to let the other things click and each student is wired differently, so that's where our clinical judgment comes into play.

For the students who were really easy to, who quickly picked up the R and it was easy to elicit, maybe it doesn't make as much sense. Or maybe it's something we need to revisit if it's impacting their reading still. We want to, like you said, keep our eyes open and consider all of these pieces. But I think that's just, you're right. It's something that not everyone thinks about in terms of perception tasks, and I'm so glad that we got to discuss that.

Lindsey: Me too. It's something that I think is a key, really, for a lot of kids. Because again, if you want them to self-monitor, we need them to be able to judge their own speech. And I think it's just such a critical piece for so many students. And what you were saying kind of brought up for me, I think it's important to note the assessment really never ends. We are constantly, every single session, you are learning more and more and more about this kid. And the initial assessment is just one snapshot of one day and you're doing the best you can to figure out what's going on and what direction you need to go and the best steps to get there.

But I think it's okay, and I think it shows excellent clinical skill to be frank, if you figure out like, "Whoops, I got that wrong." And then pivot. That is okay. We are always learning more about the student. We're always learning more about what works best for them. We're gathering information from research or from whatever our favorite way to learn more about speech language pathology is. You never know everything and the more you know the more you know you don't know. And I think it's okay to always be assessing and reassessing and adjusting and pivoting and that's... Anyway, I just wanted to throw that out there.

Marisha: I love that. That is such a good lesson and just a perspective to work on. And it also decreases some of the pressure of that evaluation. You're right, it is a snapshot in time. We are doing our best and we're trying to look at the pieces and not remembering to do a structural functional exam. We can learn from that. If we find out that there's something going on later on, then that's okay. But I think we can have a good framework and then continue to keep our eyes open.

Lindsey: I mean, we're always doing our best. And what you were saying about, you don't even want to admit how long you were working on elicitation with some kids. I've totally been there and I think we all have. And oh my gosh, there's so much that I look back even a year ago and I'm like, "Oh, I cannot believe." Well, I mean, knowing what I know now, I would've done that so differently. And that's just the way it goes. And I think we all have that, but it also shows signs of growth. And we're just always doing the best we can with what we have and that is enough because it just has to be.

Marisha: Yeah, absolutely. I love it.

Lindsey: If I could, one more thing, even this conversation has given me new ideas for this R assessment I've been working on. And the way I'm designing it, so I'm going to talk about this resource I'm designing, but this applies to anything. My vision for this is for those kids, like you mentioned, who have been in speech for however long and they just still don't have their R, I want people to be able to bust this out and be like, "Okay, we're starting from the beginning." And go back and figure out what those foundational skills might be that we're missing. Because, like we just said, we're always, as professionals, learning and growing. And if you've had a kid in your speech room for six months, a year, two years, three, whatever it is, you probably know more now than you did when you started.

And it's easy to get kind of just in a rut. And sometimes I feel like it's helpful to have another therapist come in and look at them if that's even an option. But I think it's okay to just go back to the beginning sometimes and go back and look at your paperwork. Go back and look at your assessment. Take what you know now that you didn't know six months ago and go back and see if you can't fill in some of those holes. And I just want to encourage anybody, if you feel like you are not making progress with a student, the initial assessment is not your only opportunity to assess. Go back and look at it again.

Marisha: Perfect. Yeah, like I said, if it's ready, I will link in the show notes. I'm excited to see this thing.

Lindsey: Thanks. I'm...

Marisha: Awesome.

Lindsey: Who knows when it'll be ready. I have no idea, but I hope it's awesome when it comes out.

Marisha: Yeah, it definitely will be.

Lindsey: Thanks.

Marisha: So awesome. Well, thank you so much, Lindsey. This was an absolute treat and I'm so grateful for you being so generous with your time. If people want to connect with you after listening to all of your awesome content, where can they do that?

Lindsey: I'm most active on Instagram, Speechy Things, spelled with a Y. I'm barely on Facebook. I'm curious about Twitter. I'm trying on YouTube, but Instagram's definitely the biggest place. Or you can go to speechythings.com. I have a lot. I mean, like I said, for the past year and a half, I've just totally focused on R. So that's most of what you'll find. But I have tons of free resources on my website and on Teachers Pay Teachers to help you rock the R as I like to say.

Marisha: Love it.

Lindsey: Just thank you so much, Marisha. I love talking to you.

Marisha: Likewise. We'll see you guys next month for another topic.

Thanks for listening to the SLP Now podcast. If you enjoyed this episode, please share with your SLP friends and don't forget to subscribe to the podcast to get the latest episode sent directly to you. See you next time.