Tuesday, February 5, 2013

How to select a Speech Language Pathologist

For most children with autism, a Speech and Language Pathologist (SLP) is a must.  In many cases, an SLP is who a child will see first when they present with language delays or problems with social communication.  But like all professions, there are good SLPs and bad ones, and SLPs better suited to work with different populations than others.

Since A was diagnosed, we have seen (between both children) at least eight SLPs.  Of those eight, two were truly helpful, and two tried really hard.  The other three, not so much.  One we considered was so hostile to behaviour therapy she told us flat out she would not work with any family that used it.

So, beyond the obvious statement, make sure your SLP is validly registered in your jurisdiction (in Ontario, the College of Audiologists and Speech Language Pathologists, or in the rest of Canada, the Canadian Association of Audiologists and Speech and Language Pathologists).

Here are the other important considerations:

1.  Are they willing to work within an interdisciplinary team?

Most families treat autism with a variety of professionals, especially behaviour analysts and occupational therapists, but also potentially naturopathic doctors, music therapists, or others.  One SLP we worked with was convinced Floor Time was the bomb, and she would consider nothing else.  If any SLP is preaching one way as the only way, run away.  A good SLP will work with anyone you want, even if they are skeptical of the treatment approach.

2.  Do they understand your child's needs and cognitive ability?

First, a lot of children with classic autism have some degree of cognitive impairment.  This is not true of children with PDD-NOS or Asperger Syndrome.  Understanding a child's developmental level is crucial to understanding how to bring them along by using developmentally appropriate (not age appropriate) activities.

Second, many SLPs have a very top-down orientation.  That is to say, they want to teach understanding, and then use that understanding to shape a child's behaviour, or what they will do having that understanding.  As humans age, this is the proper way to teach - we have some understanding (even as very young children), so we act accordingly.

However, some children with autism, particular very young ones, or more severe ones, do not possess enough cognitive ability to understand.  So we have to switch to a bottom-up approach, and this is where we use the principles of behaviourism or ABA.  When you use this approach, a child doesn't need to understand why they are doing something, only to act in a certain way given a recognizable circumstance.  The "why" is never taught, which is a key problem in generalization - to truly generalize something, you need to know why you are doing it, because you can never truly memorize all of the circumstances.  You can approximate, but you'll never quite get all the way there.

Many SLPs have a tough time switching from top-down to bottom-up unless they work with a lot of children with severe autism.  

In terms of needs, any good SLP will begin with an assessment to get a sense of where they are starting, and then develop goals to know where they are going.  The goals should be SMART - specific, measurable, attainable, relevant and time-bound.  Most SLPs can do the specific, measurable and relevant part, but they miss attainable and time-bound.  A good SLP will modify goals after time to ensure therapy money is not being wasted.

Last year, we spent thousands of dollars (intensive 2 hours a week therapy) working with our current SLP to use a technique called PROMPT to get A to speak.  While this did increase A's sounds tremendously, she still could not form words consistently, and words she acquired she later lost or could not use consistently later.  When I asked this SLP about goals, she agreed that for the present time continuing to work on some single words was appropriate, but A's daily communication could best be met through Augmentative Communication.

3.  Do they have any experience working with verbal children with autism?

If your child is verbal, you need to know the answer to this question.  Typically developing children with language delays are very socially motivated.  SLPs with no experience with autism find it very challenging to engage children with autism when they have no practice doing so.  If they cannot describe how they work with such children, walk away.

The Hanen program "More Than Words" is particularly useful for verbal children with autism and most SLPs in Canada have this training.  If they do, it is a good sign.

4.  Do they have any experience working with non-verbal children with autism and AAC?

When A was 16 months we took her to see a very young SLP.  This woman was completely lost because at the time, A was totally unreachable.  Social interactions were rare, crying was the norm for requests.  Clearly, she was out of her element.  We did not stay with her very long.

When A was older, we worked with another SLP, and this one was very experienced.  However, she was completely untrained in the Picture Exchange Communication System (PECS), which has a very specific protocol for teaching using behaviour techniques.  At the time A was at phase IV - requesting with two pictures.  This SLP was signing to A using total communication as well as prompting her to use 4-5 pictures on a sentence strip.  A was simply overwhelmed at all of these new techniques.  Sign was too abstract, and there were too many pictures and they represented some abstract concepts (especially adjectives) she had not yet learned.  Clearly, this SLP did not have experience in the AAC we were using.

Because most children with autism develop speech, it is very hard to find good SLPs who know what to do with AAC devices, sign language or PECS.  For most children, AAC is a stop along the way to speech, but for some, like A, it is where they will stay.  

5.  Is this a person with whom you feel comfortable?

In the end, you will be spending a lot of time and money with your SLP.  Even if it's not your money, it is time you will not get again, so make sure you don't waste it.  The rapport the SLP has with you and your child is crucial to success.


  1. Out of interest, have any of your speech therapists spoken about the use of non verbal language? I don't mean sign language. I am talking about referencing facial expressions and body language for information (not trained to look). Also have they spoken about how to use declarative language to invite a response. Also pausing to allow for extra processing time... sorry, lots of questions I know, however, I am interested to get a Canadian perspective! :-)

  2. Di, here in Toronto, there are many one or two who will agree to that. I once attended a workshop geared towards SLPs, and it was delivered by an RDI consultant.
    It was brilliant, to hear their questions and for him to explain and pretty much just give them a whole new perspective. Most of them were closed in their heads to accept....some were very interested. It takes a lot of courage to accept that maybe everything you learned about something may not actually be correct..and that you have to re-learn some bits (and then not charge 120 dollars for it, because that's almost criminal)

    Like I know one slp in toronto who charges 180 dollars an hour (yes its true) to do some RDI like stuff...but I mean I can do that for free for my son :D and all day pretty much if I want....