Speech therapy caseloads can get into the triple digits in some school districts, reducing the amount of direct contact time each child gets with the speech-language pathologist and leading to burn out among professionals. Even in districts with more manageable caseload sizes, school SLP caseload and workload size still are ongoing points of concern. It can sometimes seem like kids are getting added to the caseload faster than they can graduate speech. This post covers four tips to help optimize and accelerate treatment for goals targeting speech sound disorders. By boosting kids’ speech clarity, we can increase their participation in academics and other functional activities, free up therapy time to focus on pre-literacy, literacy, or language goals, and hopefully impact these other skill domains as well by resolving one area of communication impairment.
Why Does Treatment for Speech Sound Disorders Take SO Long
Articulation therapy has long been the bread and butter of the field of speech-language pathology. However, in recent years, more push has been given towards acknowledging that SLPs are more than “just” speech teachers. Given the scope and breadth of SLP practice, language and literacy goals are often viewed as the front runners for functional impact areas of focus. Plus, treatment for speech sound disorders is highly repetitive and it can be hard to engage some kids in sessions. Despite this, we know that treatment for speech sound disorders works, and the ability to be understood by peers and other people can have a profound impact on a child’s academic success and self-esteem.
While it’s challenging to determine the exact dosage needs for habilitating a speech sound disorder, a few researchers have given us numbers to reference as a starting point. In one study, Jacoby and colleagues examine the impact of hours of treatment on improvement in Functional Communication Measures from the ASHA National Outcomes Measure Project. They found that 76.5% of participants increased at least one FCM after 20 hours of therapy. Children who had comorbid diagnoses, like syndromes or hearing loss, often needed more hours of therapy to achieve progress.
Sugden and colleagues have reported on both the trends in research studies regarding dosage needs for improvement in phonological impairment and compared this with trends noted in surveys of practicing SLPs. In research studies, the authors note intervention typically occurs two to three times per week, in sessions containing 100 production trials, for 3–46 months. Conversely, they report SLP survey results suggesting a status quo of 30 minute sessions consisting of 21–50 trials scheduled twice per week, for an average of 78.3 sessions over 16.0 months.
If we use the average of 20 hours of therapy needed for a gain of one Functional Communication measure, and assume about 100 repetitions per hour, we’d expect kids to need about 2000 repetitions per movement up the scale. Based on the numbers reported in the analysis of research studies, 100 trials per session, twice per week, for 46 months, would give us an estimate of 36,800 repetitions for speech improvement! These are massive amounts of repetition needed to impact change in motor learning. It’s no wonder kids are slow to make progress and graduate from speech if they’re receiving one 30 minute group session with three other kids. If they’re only completing 25 repetitions per week, it’s going to take years and years to make progress. How can we help accelerate this process?
1. Speed progress by making every speech repetition high quality
Given the amount of repetition needed for motor learning for speech sounds, we want to make sure we’re not reinforcing incorrect movement patterns and making practice counter-productive. It’s critical that treatment follows principles of motor learning to include both quantitative and qualitative knowledge of results. This means that in the early stages of teaching a new sound, the speech-language pathologist provides explicit instruction to the student about how the sound is formed and ensures that they’re able to produce the motor plan accurately before initiating a phase of high frequency drill.
Working on target sounds in isolation, or at syllable level, or in words with a facilitating context (one where the sound is easier for the child to produce) helps ensure that children are producing sounds accurately. By making sure they’re able to succeed with the production, they can have the maximum benefit from repetitions they do practice.
2. Accelerate speech progress with frequent repetitions at home or outside of the session
After kids know how to produce the target sound accurately (for help, check out our “how to” series on the blog!), the next step is to try and start chipping away at those repetitions. We want kids to practice the correct movement enough times that they start to internalize this new motor pattern and replace the incorrect pattern.
Achieving all of this repetition in the speech session alone isn’t realistic when aiming for a feasible time frame for improvement. Home practice programs have a number of benefits for the process. The first is that some of this repetition gets transferred from the therapist’s schedule. This allows the therapist to work with that same child on other areas of need, or in teaching the next sound they need to work on, or to focus on a sound that’s harder for them to produce accurately, where they need more support from the skilled SLP. Doing repetitions at home gives the SLP the ability to manage their time with the child more effectively.
Doing repetitions at home also can help with generalization of skills. Generalization refers to the ability of the child being able to produce the new motor pattern in a variety of different contexts, not just those directly practiced in the therapy setting. The faster kids generalize what they learn, the sooner they’ve mastered the speech skill. If kids only practice in the therapy room, it may be harder for them to use their target sound accurately in other settings, like their classroom or at home. Some kids can get very good at learning the expectations of the therapy session and may even be able to use the newly learned motor pattern in conversations with the SLP, but in other settings, the same old errors pop up. By incorporating a home program into the therapy plan early on, we can capitalize on every opportunity for generalization.
Home practice also helps parents get involved in their child’s education and treatment plan. By including parents and caregivers in the progress, we can support the family’s goals for better communication. Sometimes parents may not notice progress in speech sound goals if they never hear the child practice at the level they’re able to succeed—it can take awhile before kids are able to master the sound and produce it in every day conversation. But, along the way, they’re getting better and better at making the sound in syllables, words, phrases, and sentences. By letting parents get in on the repetition work, they can experience some of those steps and the success that’s happening throughout the process.
3. Identify kids who aren’t making expected progress
If kids are able to produce a sound correctly with support and provided with enough opportunities to repeat the correct motor pattern, progress will follow. While there’s room for interpretation regarding the most appropriate target selection and treatment plan for any given child, as a general rule of thumb, all children who have speech sound goals should be demonstrating steady improvement with respect to accuracy at a given level of focus. Put another way, if kids aren’t increasing in accuracy at a level of instruction across two to three sessions, something is off in the process.
It may be that the instructional level is too difficult, and the child is unable to succeed at the task. It may be that they haven’t repeated the skill enough to drive motor learning. It may be that the task is now too easy and they haven’t levelled up to the next stage in complexity to encourage further growth. Understanding where kids are performing and what their trajectory of change is helps to identify those who may need a tweak in course.
If the child is improving—great! Could they be improving faster? Some kids can move up a level of the speech hierarchy every two weeks per target sound. Increasing the number of repetitions in between each session could help to further stabilize learning to allow the SLP to advance them more quickly from session to session.
If the child isn’t improving and session performance is at a high level (above 80%)—the task is probably too easy and they need to move up to a higher level of the speech hierarchy to make further progress.
If the child isn’t improving and session performance is consistently low (below 60 or 70%)—the task may be too difficult and the child needs more instructional time, or to move to a lower level of the speech hierarchy to help improve success in order to maximize the benefit they get from repetitive drill. Note- Movement from 20% to 30% would be progress, so what we’re focusing on here is more specifically NO progress (e.g. stuck at 40% over time), not specifically the accuracy itself.
4. Understand whether opportunities for repetition are adequate
Teaching correct movement for target sounds and selecting the correct level of appropriateness of stimuli is a skilled task that speech-language pathologists are trained to complete. Supervising thousands of repetitions of target productions requires skill as well, but due to the highly repetitive nature of the task, can be taught and removed in part from the workload of the SLP. Additionally, when children demonstrate high levels of success following SLP instruction and can work on self-monitoring under direction of the SLP, the chances for counter-productive mistakes made during the repetition phase are low.
So, how do we help determine if the opportunities for repetition are enough for efficient progress? In truth, this will likely vary from child to child, but in most cases, more is better. As with any motor learning task, the more practice you get, the more quickly you master the task, and the sooner you reach higher levels of proficiency.
At a minimum, we have some general numbers of repetitions typically reported in clinically based research studies to help guide our recommendations. Based on these reports, we should expect that kids need to accomplish 100 to 300 repetitions of correctly produced target sounds each week. Children who have multiple sounds in error, or co-occuring language disorders, an apraxia diagnosis, cleft palate, or other developmental delays, may need to fall towards the higher end of that range or above to help stabilize correctly produced motor patterns learned in the speech session. Only with enough repetition can we see stabilization and be able to help advance kids to the next stage in their treatment.
If an SLP’s caseload size prevents them from directly supervising 100 to 300 repetitions of a target sound weekly, then a home practice program must augment the direct time of the SLP for progress to occur.
Home programs present their own unique challenges, as compliance issues may occur. Families may be unaware of the program, may struggle with busy schedules or other stressors, and it may be challenging to engage children in home practice. However, in order to move the needle on speech progress, kids need opportunities for repetition of motor patterns for correct speech sound production.
What's the next step for increasing repetitions for speech progress?
By looking critically at the caseload distribution of SLPs and understanding whether all the needed components are in place for progress, we can help accelerate kids’ performance on speech goals. Verboso offers a comprehensive platform that allows SLPs to individualize practice stimuli to each child’s needs and select what stimuli kids are presented with during home practice. Parents simply log kids into video games, and kids can practice while they play, increasing opportunities for much needed repetition at home. Read more about our speech games, and set up a demo of our solution to see if Verboso can help your speech caseload make faster progress.