The scope of the problem

In the UK:

• 2.5 million people have a speech or language difficulty.^[1]
• 5% of children enter school with difficulties in speech and language.^[1]
• 30% of people who have had a cerebrovascular accident have a persisting speech and language disorder.^[1]

In the year 2004-2005:

• There were 346,000 initial contacts, or new episodes of care, made by speech and language therapists working in the NHS in England.^[3]
• Most of these referrals were made by hospital consultants in general medicine, geriatric medicine and ear, nose and throat specialties.^[3]
• 38% of referrals were for preschool or school age children.^[3]

Typical patients seen by speech and language therapists^[2]

These include:

• Babies who have problems with feeding and/or swallowing.
• Children with:
  • Learning difficulty
  • Physical disability
  • Language delay
  • Difficulties in sound production
  • Hearing problems
  • Cleft palate
  • Stammering
  • Autistic spectrum disorders
  • Dyslexia
  • Voice disorders
  • Selective mutism
• Adults with:
  • Eating, swallowing and/or communication problems following stroke.
  • Neurological impairment or degenerative conditions such as head injury, Parkinson's disease, motor neurone disease and dementia.
  • Cancer of the head, neck or throat (including laryngectomy).
  • Voice problems.
  • Mental health problems.
  • Learning difficulty.
  • Physical disability.
  • Stammering.
  • Hearing problems.

Training to become a speech and language therapist

There is a three- or four-year degree course accredited by the Royal College of Speech and Language Therapists (RCSLT) and graduates are registered by the college. A two-year postgraduate qualification can also be taken if the candidate has an appropriate first degree. All speech and language therapists are registered with the Health Professions Council (HPC). To be registered, speech and language therapists must meet the Council's standards for their training, professional skills, behaviour and health.

Speech and language therapy (SLT) assistants, support workers and bilingual coworkers also exist. These team members work alongside a speech and language therapist, including working with clients on a one-to-one basis, assisting in group therapy sessions, clerical and administrative work or advising on culture and language differences.^[1]

The evidence base for speech and language therapy

Speech and language therapy (SLT), like every other aspect of medical care, should be subjected to vigorous scientific appraisal. Trials have been undertaken in the field of SLT. Evidence from large, randomised controlled trials (RCTs) is the gold standard. A review of recent evidence has found the following:

• An RCT of preschool children with delayed speech and language looked at the differences in those children randomised to 'watchful waiting' for 12 months and those randomised to SLT. It showed limited evidence to support the effectiveness of SLT compared with watchful waiting over a 12-month period. 70% of all children still had substantial speech and language deficits by the end of the trial. The authors suggested further research to identify more effective ways of helping these children.^[4]
• A Cochrane review, published in 2003, concluded that there was some evidence for the effectiveness of SLT for children with expressive phonological and expressive vocabulary difficulties. It showed that there was mixed evidence for SLT interventions in children with expressive syntax difficulties and that more research was needed concerning interventions for those with receptive language difficulties.^[5]
• One study in the USA reported that speech therapy for children who stammer appears to do little to improve their chance of recovery.^[6] However, this was in one specific area in the USA (North Carolina) and the reproducibility of this evidence is therefore questionable. Another RCT showed that the Lidcombe Programme of early stuttering intervention was an efficacious treatment for stuttering in children of preschool age.^[7] The Lidcombe Programme is a behavioural treatment developed specifically for stuttering in children aged younger than 6. During the programme, parents provide verbal contingencies for periods of stutter-free speech and for moments of stuttering, under the guidance of a speech and language therapist (eg 'That was good talking', 'That was a bit bumpy', etc).
• A Cochrane review published in 2010 showed some indication that SLT for people with aphasia after a stroke is effective.^[8] There seemed to be some evidence that people who had intensive SLT may do better, although in the trials reviewed, more people withdrew from intensive SLT than from conventional SLT. The review also found that SLT delivered by a therapist-trained and supervised volunteer seemed to be as effective as that delivered by a professional. However, overall, there was insufficient evidence to draw conclusions about the most effective way of delivering SLT.
• Another Cochrane review found that more research is needed to determine the effectiveness of SLT in people with Parkinson's disease who have dysarthria.^[9]
• A Cochrane review looking at children with cerebral palsy found no firm evidence of the positive effects of SLT. Again, the authors noted that further research is needed.^[10] Likewise, for interventions for childhood apraxia of speech and also dysarthria associated with acquired brain injury in children and adolescents.^[11][12]

Speech and language therapy after cerebrovascular accident

At least 4 out of 10 people who have had a stroke will have swallowing difficulties.^[13] This may put them at risk of aspiration and pneumonia.^[13] Stroke patients can also have speech, language and communication problems.

The National Institute for Health and Clinical Excellence (NICE) has issued guidelines on the diagnosis and acute management of stroke and transient ischaemic attacks.^[14] Scottish Intercollegiate Guidelines Network (SIGN) has also issued guidelines on the management of patients with stroke, including guidelines about the assessment and management of dysphagia in stroke patients.^[15][16][17] As well as this, the Intercollegiate Stroke Working Party (ISWP) has issued national clinical guidelines for stroke which incorporate the recommendations from NICE.^[13] All of these guidelines recognise speech and language therapists as an integral part of the stroke care team and give specific details about when a stroke patient should be referred to a speech and language therapist. The ISWP National Clinical Guidelines for Stroke suggest the following:

• On admission, people with acute stroke should have their swallowing screened by an appropriately trained healthcare professional before being given any oral food, fluid or medication. If there are concerns, referral to a speech and language therapist (or other appropriately trained professional with specialism in dysphagia) should be made, preferably within 24 hours of admission and not more than 72 hours afterwards.
• Referral to a speech and language therapist should also be made for any communication difficulties including suspected aphasia, unclear or unintelligible speech affecting a patient's communication, suspected speech apraxia (problems with word articulation) or communication difficulties despite reasonable cognition and language function.

Conclusion

Speech and language therapists, and their assistants, form an important part of the multidisciplinary team. Their specialist training allows assessment and treatment of patients of all ages with varied and complex medical and developmental problems. They are governed by their own professional standards and guidelines, supported by evidence from the literature and consensus expert opinion.