Speech Therapy - An Introduction

Speech and language therapists assess and treat speech, language and communication problems in people of all ages. They help people to become independent communicators using speech, gesture and/or communication aids as needed. They also work with people who have eating, drinking, chewing and swallowing difficulties.¹ They work as part of a multidisciplinary team and have close links with teachers, doctors, nurses, psychologists and other health professionals. They work in hospital and community settings; on inpatient wards, in outpatient clinics, schools, health centres and client's homes. There are around 10,000 practising speech and language therapists in the UK, most of whom are employed by the National Health Service.² Speech and language therapy is also available privately, for adults and children, through the Association of Speech and Language Therapists in Private Practice (ASLTIPP).

In the UK:

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

In the year 2004-05:

• There were 346,000 initial contacts, or new episodes of care, made by speech and language therapists working in the National Health Service 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 pre-school or school age children.³

• Babies with feeding and swallowing difficulties
• Children with:
  • Mild, moderate or severe learning difficulties
  • Physical disabilities
  • Language delay
  • Specific language impairment
  • Specific difficulties in producing sounds
  • Hearing impairment
  • Cleft palate
  • Stammering
  • Autism/social interaction difficulties
  • Dyslexia
  • Voice disorders
• Adults with:
  • Eating and swallowing and/or communication problems following stroke
  • Neurological impairments and degenerative conditions including: head injury, Parkinson's disease, Motor-neurone disease and dementia
  • Cancer of the head, neck and throat (including laryngectomy)
  • Voice problems
  • Mental health issues
  • Learning difficulties
  • Physical disabilities
  • Stammering (dysfluency)
  • Hearing impairment

There is a three or four-year degree course accredited by the Royal College of Speech and Language Therapists 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. Speech and Language Therapy Assistants or bi-lingual co-workers also exist. This team member works along side a speech and language therapist, including working with clients on a one-to-one basis, assisting in group therapy sessions, clerical and administrative work and advising on cultural and language differences.¹

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

• A randomised controlled trial of pre-school children with delayed speech and language looked at the differences in those children randomised to 'watchful waiting' for 12 months and those randomised to speech and language therapy. It showed limited evidence to support the effectiveness of speech and language therapy compared to 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 also showed that there was mixed evidence for SLT interventions in children with expressive syntax and no evidence 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 randomised controlled trial 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 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 (e.g. "That was good talking", "That was a bit bumpy" etc).

Speech and language therapy after cerebrovascular accident

• SIGN have issued guidelines on the management of patients with stroke. NICE are also due to issue guidelines on the diagnosis and acute management of stroke and transient ischaemic attacks in July 2008. As well as this, the Royal College of Physicians have issued national clinical guidelines for stroke which include referral to a speech and language therapist for patients with aphasia and dysphagia.⁸
• The SIGN guidelines recognise speech and language therapists as an integral part of the stroke care team. They state that speech and language therapists should have specific involvement in the assessment and management of communication disorders and dysphagia.^9,10
• The SIGN guidelines quote that there is good evidence that people with aphasia as a result of cerebrovascular accident benefit from speech and language therapy and this improves with the intensity of treatment.,^9,11,12
• They also quote that a Cochrane review published in 2005 found that there are no large clinical trials testing the effectiveness of speech and language therapy interventions for dysarthria secondary to non-progressive brain damage (typically caused by cerebrovascular accident or traumatic injury). However, a randomised controlled trial of optimised speech and language therapy for communication difficulties after stroke has recently been commenced.¹³ Despite this, SIGN guidelines recommend that patients with dysarthria should be referred to an appropriate speech and language therapy service for assessment and management as expert opinion remains in favour of their effectiveness.⁹

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.