Let’s Talk about Speech Therapy Dosage

Do you ever struggle to decide the frequency (days per week or month) and the length of therapy sessions to recommend for a child with a speech sound disorder? If you’re school based, do you wonder how to determine which service delivery model would be best?  I sometimes did, too, but I thought that maybe I was alone in that. Well, during my last 4 years in schools, I was an SLP supervisor, and when looking at caseloads, I was shocked to see that about 90% of children (artic or language) had therapy 30 minutes twice per week on their IEPs. WOW! Surely these children don’t ALL have the exact same needs, right?

I did a short training with the therapists to discuss dosage, and now I am sharing some of that information with you! We all recognize that NOT all children need the same therapy, but sometimes it’s hard to feel confident about our recommendations. Don’t guess anymore. Learn how to make better decisions for children and…research based decisions! Can you imagine how amazing it would feel to have written recommendations from ASHA or research to back up your recommendations in an IEP meeting? You can! Let’s get to it!

Let’s start with detemining the most appropriate frequency (how many days) and duration (session length) to recommend. 

1. Consider how many phonemes or phonological processes need remediating. The more non-developmental phonemes errors, the more (or longer) sessions the child will need to remediate the errors in a reasonable amount of time. This is just good old common sense. A child with 2 errors should probably not have the same frequency or duration as a child with 22 or 50 errored phonemes, for example. PROS: You’ll be using both your and the child’s time more productively. CONS: When you get creative with therapy delivery, scheduling can be tricky.
2. For children with short or fleeting attention spans or children who struggle tolerate therapy: If 10 minutes of your session is wasted because the child is burned out or non-participative, consider shortening the session time but increasing the sessions each week. 5 Minute Kids (aka speedy speech) may be a great option, and it comes with its own research for you to use with parent, administrators, and anyone else you need to convince that this is a truly effectively delivery model. In fact, it is arguably more effective than traditional model Read the research for yourself here. PROS: Many schools in my former district implemented this with amazing success, and the schools who stuck to it dismissed a record breaking number of children from articulation or phonology therapy each year. Children, quite simply, were in therapy for an overall shorter amount of time. TIP: The school with the most success had a principal who agreed to keep 2 chairs in each grade level’s hallway at all times. That way the therapist and student had a place to sit. The SLP sent the child to beckon the next student so they stayed nicely on schedule. CONS: 1) It can be a hard sell to parents who think more is better. 2) You must stay on the schedule or the afternoon bell will ring and you won’t have seen all of your students. 3) Being in a hallway makes staying on schedule more difficult because passersby often want to bend your ear. That was my personal experience for sure. 4) You’ll have to amend many IEPS if you’re in school, and it’s not ideal (neither for billing or for parent convenience) in a private practice.
3. For children who are embarrassed by their speech errors, I personally think that group therapy is the best option. I’ve had many students who would’ve been well-served by the “speedy speech” or 5 minute kids approach, but for those who clearly felt self-conscious, “less than,” or were avoiding speaking due to their speech disorder, I opted to place them in a group. Seeing that other kids just like them had the same problem boosted their self-esteem and helped to squash at least some of their self-consciousness. It gave them a safe place and friends who shared a common struggle. PROS: The child gains confidence and an affirming peer group. CONS: This can be difficult to schedule, and of course, it increases the size of your group. Groups on the small side are ideal so that each child gets enough “face time” with you, the expert they need to improve.
4. For children with Childhood Apraxia of Speech, there is a common concensus that therapy must be frequent (3-5 days per week according to ASHA) and intensive. In schools, I saw children with CAS 5 days per week unless it meant they would not get any enrichment each week (art, PE, computer lab, library), in which case I would only see them 4 days per week. As someone who is very passionate about treating CAS and who has treated many children with this SSD, I’m here to tell you that this frequency is crucial. Even with intensive therapy nearly everyday, remediation takes many years. Read more in ASHA’s practice portal. PROS: Progress will come, but it is slow and will be slower without this degree of frequency and intensity.  TIP: Once you believe the child can have success with word shapes or other “homework,” it’s crucial to get parents on board and to educate parents about their child’s disorder and how to complete the homework you send. I also encourage parents to get private therapy, if possible. The more, the better. CONS: This intense, frequent therapy can be very frustrating for the child and possibly for you. It is sometimes diffcult to schedule based on what you are allowed to pull the child from in the school setting. For private practioners, this can be both cost and time prohibitive for the parent.

 

Let’s talk about Service Delivery (the location where or conditions under which the therapy will take place).

Who with SSDs can you serve outside of your therapy room?  For children who are near dismissal or just need to work on carryover, consider a service delivery model outside of the classroom. It’s crucial that they learn to use their new communication skills outside of the therapy setting. As I like to say, “Don’t save your good speech for me! Show the whole world!” I’ve had some favorite (and successful) alternate locations including the cafeteria, the playground (great for kids who need movement), the classroom, or “Speech Club.”

• • “Speech Club” can happen anytime you can swing it, for me me it was from the time the child got off the bus or out of their car until the first bell in a decided upon location – which was sometimes the hallway if I had hall duty. You don’t even need to plan anything. These children will talk amongst themselves so much that you can take conversational data on each of them. Their minutes should be much less frequent than children who still have severe disorders. In fact, as children progress, we should continually be reducing minutes to prepare the parents. This also shows the parents that progress can continue without pulling the child out of class all the time. Always back to that good old Least Restrictive Environment rule when needed. It’s hard to be successful in school when/if you’re not in class. By the time they’re in the generalization phase of therapy, they should only be getting monthly or bi-monthly sessions (IMO).
  • Of course, the classroom is a very feasible place to provide therapy for students in the final phases of therapy, too. If the classroom is a hopping place with lots of the discussion or if you’re there during an interative time, it’s most ideal. Over the years, I’ve put visual cues on the student’s desk on in their agenda that they carried around and opened at the start of each period. I also recommend educating the teacher about how to discreetly give cues to the students. Some teachers embrace it while some don’t, but when it works, it’s magic. Oh, I have a friend, Sparklle SLP, who is required to provide all articulation therapy inside the classroom. See her articulation resources that were especially made for push-in therapy HERE. She’s done a brilliant job with this very tough expectation.
  • Take kids on the playground instead of your therapy room. It’s more naturalistic and will better facilitate generalization. This is a MUST for kids who can’t contain their energy during therapy, but set ground rules first like, “Five good words, and then you can slide” or “You have to say your sound each time I push you on the swing,” etc. I always aim for at least 100 trials per session, but with kids who are movers and shakers, I take what I can get!
  • The cafeteria can be awkward and even embarrass students, but if you’ve been at the school a long while and are well liked, kids will be happy to see you steal a seat at their table. It’s a great place to generally assess your close-to-dismissal student’s carryover- even if you don’t take a seat, you can hover around their table and listen in.
  • TIP: START TALKING ABOUT DISMISSAL/DISCHARGE FROM THE VERY FIRST ENCOUNTER WITH THE PARENT. Let them know that the goal of therapy is for the child to NOT NEED US anymore. Talk about this as much as possible throughout the course of therapy so that when it’s time to dismiss or discharge, there is a celebration instead of an argument.
  • PROS: This service delivery facilitates generalization and carryover and gets lots of students seen at one time. Plus, they start to keep each other accountable.
  • CONS: If you have morning duty, this gets complicated. Maybe be shoot for a “lunch bunch” instead. If you are in school and have morning duty, ask your admin to remove you from it so you can serve more students. Use your schedule for evidence if that is the only time you can squeeze in more students. The ideal time for me was during that space between drop off and first bell to see large groups with mild SSDs or those only working on carryover.

SPOILER ALERT: You may not have time to do ANY of this. I get it. Your schedule may not have one free space on it. That’s reality. Try your best to think creatively. For several years, my principal (who has a sped background) agreed to lump all kids with SSD among 1 or 2 classes which made scheduling much easier. She did the same for my language students.

BOTTOM LINE: Take a good hard look at your caseload. Are all of your SSD clients or students getting the same amount of therapy? If so, there’s something wrong with that. Think of your most severe SSD student – the one that is unintelligible even to you. Now think of the students who are close to dismissal. Then, imagine a scale from most to least severe. Make decisions based on their actual need and severity.

Want to keep discussing about this topic? Got questions? DM me on Instagram or email me at miamcdaniel@gmail.com to keep the conversation going!

While you’re here, snag this FREE articulation visual that I use in therapy with students to help them to become more self-aware and accountable regarding their speech progress AND to educate parents about the progression of articulation therapy.

Thanks for reading, and stay tuned on for my next post about dosage for language therapy!