Speech Therapy Overview
Speech therapy, preferred term speech-language pathology (SLP), is the profession devoted to assessment, habilitation, rehabilitation, counseling, and prevention services for individuals from birth through old age who have some type of speech, voice, language, cognitive-communicative, or swallowing disorder. The professional who provides these services is called a speech-language pathologist (speech-pathologist, speech therapist, speech-language therapists, speech clinician, teacher of the speech and hearing handicapped). Other roles speech-language pathologists fulfill include advocacy, research, program coordination and administration, college teaching, supervision, product development and evaluation, and consultation with families, caregivers, educators, other rehabilitation specialists, administrators, medical professionals, and others. Speech-language pathology is part of the discipline of communication sciences and disorders which also includes audiology. This entry focuses primarily on speech therapy as practiced in the United States (US) with a section devoted to international practice.
Undoubtedly throughout the ages, there have been individuals interested in helping others communicate more effectively. The profession of speech-language pathology, however, grew historically in the US from an integration of disciplines including elocution, education, psychology, linguistics, communication, and medicine. While early practitioners often focused on elocution and oratory, they recognized the need to help those with communication disabilities such as stuttering and hearing loss. As interest in the brain and communication emerged through the nineteenth and twentieth centuries, the profession blended a focus on rehabilitation techniques with the scientific study of normal speech, language, and cognition and communication disorders. Early speech-language pathologists typically had undergraduate degrees in "speech-correction," but as the scope of practice and scientific base increased, the need for more highly qualified practitioners expanded. This lead to the development of programs of study in over 300 US colleges and universities where students could study the scientific basis underlying the professions, learn about diagnostic and therapeutic methods for a variety of communication disorders, and practice under the guidance of master clinicians prior to independent practice in educational, medical, private practice, or other community settings.
As the profession grew in the US, national, state, and local professional associations were created and provided an ethical basis for practice and created opportunities for networking and sharing information through regular publication of journals and annual conferences. University professors and researchers expanded the scientific basis, sought national funding for research, and published results in peer reviewed journals. More recently, advances in technology and inclusion of dysphagia (swallowing disorders) have greatly expanded the profession. An excellent history of the profession of SLP is available at Judy Duchan's website Getting Here: A Short History of Speech Pathology in America (See Resources).
Scope of Practice
In the US, state licensure laws and professional organizations, such as the American Speech-Language and Hearing Association (ASHA), define what professional practices are within the range of skills of a fully qualified practitioner. ASHA's Scope of Practice in Speech-Language Pathology (2007) is a detailed and living document that outlines the specific services speech-language pathologists can do including providing prevention, screening, consultation, assessment, treatment, management, counseling and follow up services for disorders of speech (articulation, fluency, resonance, and voice, language (including receptive and expressive oral, written, graphic and manual communication), swallowing and upper aerodigestive functioning, cognitive aspects of communication, and sensory awareness related to communication, swallowing and upper aerodigestive functions. Also included within the SLP scope of practice is assessment for, selection of, and intervention involving the use of augmentative and alternative communication techniques and strategies, providing services to those with hearing loss, screening hearing, using instrumentation, selecting, fitting, and establishing effective use of prosthetic or adaptive devices for communication, swallowing and other upper aerodigestive functions, assisting in the assessment of and providing therapy for those with central auditory processing disorders, educating and counseling individuals, families, and others regarding communication and swallowing disorders, advocating, collaborating with other professionals, addressing environmental factors affecting communication, providing services to enhance communication performance such as accent modification and the professional voice, and providing services that are culturally appropriate. The scope of practice is modified as roles and responsibilities change. Note, too, that professional SLPs are expected to know what skills they have and not to practice beyond their own personal abilities or scope of competence.
In the US speech-language pathologists provide a full range of services in educational settings (preschool, elementary, secondary public and private schools, and colleges or universities); health care settings (general, specialized, and veteran's administration hospitals, in and outpatient rehabilitation facilities, long term care facilities, home health care, offices of other health care practitioners); early intervention programs; community rehabilitation centers; adult day care centers; local, state and federal government agencies and departments; private practices; colleges and universities; research laboratories; and industry.
Close to 70 percent of speech-language pathologists in the US work full time. Approximately 60 percent of speech-language pathologists work in educational type settings, with the remainder employed across a variety of health care, other rehabilitation programs and settings (Slater, 2007). In general, practitioners in school settings work a typical school year (approximately 9-10 months) and those in other settings work a 12 month calendar year. While many practitioners are employed by specific settings, some work on contract through agencies that deploy them as needed to a variety of employment settings.
An emerging way to offer diagnostic, intervention, and consultation services is through telepractice which uses telecommunication technology to link SLPs with clients or other (ASHA, 2009b). Telepractice can be used to extend clinical services to those in remote areas, the underserved, or those with limited personal accessibility to services. It also extends the ability of speech-language pathologists to interact with other professionals and access diagnostic and therapy technology and expertise.
According to the Bureau of Labor Statistics (2009) growth outlook for SLPs in the US is faster than average. Between 2008 and 2018 there is expected to be a 19% growth in the need for SLPs. Job outlook is particularly good for those who speak a second language (e.g. Spanish) or who are willing to relocate to areas with underserved populations (e.g. remote and rural areas). Job outlook is influenced by the number of those with communication difficulties, the increasing number of elders, medical advances, the emphasis on meeting the needs of students with special needs and literacy in the schools, and changes in health care funding. Salaries are dependent on years of experience, type of setting, and geographical region in the US.
Education, Accreditation, Certification, Licensure
In the US SLPs may begin their preprofessional education at the undergraduate level which emphasizes basic sciences, liberal arts, linguistics, normal development, and introductory courses in speech, language, and hearing assessment and disorders. The bulk of the educational and practicum experience, however, is at the master's degree level (e.g. MA, MS, M.Ed) and focuses on knowledge and skills requisite to professional practice. Students fulfill educational and practicum requirements that lead to ASHA Certification (Certificate of Clinical Competence or CCC-SLP) as a speech-language pathologist and usually requirements for individual state licensure and/or teacher certification. Graduate coursework focuses on achieving clinical competencies that are needed to work with a variety of disorders, clients, and settings. Most SLPs also participate in continuing education after their graduate degree to maintain currency in their profession.
Educational Program Accreditation: The Council on Academic Accreditation in Audiology and Speech-Language Pathology (CAA) of the American Speech-Language-Hearing Association accredits graduate programs in audiology and/or speech-language pathology. This is a voluntary program that provides standards for entry level professionals and grants certificates to programs that have fulfilled all standards.
Professional Certification: Since 1952 many SLPs have fulfilled initial and continuing education requirements for the Certificate of Clinical Competence (CCC-SLP) offered by the American Speech-Language-Hearing Association. Standards are set by its Council for Clinical Certification in Audiology and Speech-Language Pathology. Standards focus on degree earned, college or university accreditation and resources, knowledge outcomes, skills outcomes, assessment, a clinical fellowship year following graduation, and maintenance of certification. In 2010 there were about 140,000 professionals in the US who held the CCC in speech-language pathology or audiology. (See ASHA, 2010b).
Ethics and Professional Liability
Ethics: The maturing profession of SLP in the US recognized that it needed a Code of Ethics to define standards of practice and provide a framework for professional behavior and responsibilities. In 1930 the American Speech-Language and Hearing Association created the first Code of Ethics that is binding for all members, certified nonmembers, applicants, and clinical fellows. This document has gone through a number of revisions as scope of practice expanded. ASHA also has documented procedures for filing and reviewing complaints against professionals who may have committed ethical violations, an appeals process, and a variety of sanctions for those who have committed unethical practices. Codes of Ethics may also be promulgated by state and local associations in addition to ASHA. See Resources for reference to ASHA's Code of Ethics.
Liability: At times, speech-language pathologists may provide services that are substandard and may be held legally liable for their professional misconduct or lack of skill. Speech-language pathologists have a professional duty to know what duties they may perform, their level of skill to implement these competently, the state and national laws that affect their service delivery, and how to prevent the possibility of a malpractice lawsuit. Many speech-language pathologists obtain professional liability insurance from their employer, ASHA, or other insurers.
The primary national professional organization in the US to which SLPs belong is the American Speech-Language and Hearing Association (ASHA. Founded in 1925, ASHA has grown from a small group of professors at the University of Iowa to a membership of over 140,000 that includes SLPs and audiologists. In addition to providing standards for college/university programs and for clinical practitioners, ASHA serves as a resource for those with communication disorders, advocates for issues related to SLP and audiology at the national level, works with state organizations, and provides a Code of Ethics, professional education and conferences, and numerous peer reviewed publications and clinical materials.
There is also a 13,000 member student association called the National Student Speech Language and Hearing Association (NSSLHA) that has chapters in about 300 colleges across the US. Full and part time undergraduate or graduate students may join. NSSLHA publishes a journal called Contemporary Issues in Communication Sciences and Disorder and a newsletter NYSSLHA Now, sponsors numerous activities at local and national levels of interest to students, and participates in governance activities of ASHA.
SLPs in the US may also belong to state and local professional organizations. For example, in New York State, the New York State Speech Language and Hearing Association (NYSSLHA) serves the professional needs of SLPs with respect to state legislation, state licensure, ethical practice, continuing education, and other relevant issues.
Many communities also have local speech-language and hearing associations that serve as a grassroots organization for SLPs. These organizations provide networking and continuing education opportunities for both practicing clinicians and students from local colleges.
In addition, some SLPs may join international associations such as the International Association of Logopedics and Phoniatrics, the International Society of Augmentative and Alternative Communication, the International Association of Laryngectomees, and the International Association of Orofacial Myology. These organizations offer SLPs opportunities to network, participate in continuing education, and present research with professionals from around the world in annual meetings and conferences.
SLPs may also participate in allied organizations such as the Academy of Neurologic Communication Disorders and Sciences, the American Cleft Palate-Craniofacial Association, the Brain Injury Association of American, the Council for Exceptional Children, the National Aphasia Association, the National Stuttering Association and the Stuttering Foundation of America. Participation in such organizations allows SLPs to interact with professionals with specialized expertise. SLPs often work closely with local branches of national organizations such as the National Stroke Association, the National Aphasia Association, and the American Cancer Society.
Speech-Language Pathology is an established or growing profession in Europe, North and South America, Asia, Africa, and Australia. In the European Union there are about 50,000 speech-language pathologists or logopedists (Standing Liaison Committee of Speech and Language Therapists and Logopedists, 2010). In some countries, (e.g. Brazil) Speech-Language Pathology and Audiology are considered one profession (Fonoaudiologia) and are taught conjointly. Educational preparation for speech-language pathologists varies greatly throughout the world. For example, in Europe it may include three or four year undergraduate programs, graduate degrees and certification or registration with professional associations or state or provincial governments. In some countries special education teachers or other interested individuals take minimal educational training as preparation for employment as a speech-language pathologist. Bleile, Ireland, and Kiel (2006) state that at least 51countries have post-secondary education for speech-language pathologists in about 672 student training programs. This includes about 300 programs in the US and 100 in Brazil but only one in China. New programs are being developed in Bangladesh, Iceland, and Singapore. In general, SLP services and professional training are less available or nonexistent in the poorest countries of the world.
In some countries, for example Canada, SLP assistants (Communication Disorders Assistants- CDAs) are trained in intensive college based programs to serve as adjuncts to SLPs. Their work includes implementing intervention programs established by SLPs following their evaluations. See Resources sections for reference to this program.
At least 55 countries have national professional organizations that focus on communication disorders (Bleile, Irleand, and Kiel, 2006). Some of these associations also publish peer reviewed journals. Examples of these include the Canadian Journal of Speech-Language Pathology and Audiology published by the Canadian Speech-Language and Hearing Association, the Asia Pacific Journal of Speech, Language and Hearing published by the Asia Pacific Society for the Study of Speech, Language and Hearing, and the International Journal of Speech-Language Pathology published by the Speech Pathology Association of Australia. Only two sub-Saharan professional organizations exist: the South African Speech Language Hearing Association that publishes the South African Journal of Communication Disorders and the Nigerian Speech and Hearing Association. For a complete listing of international associations see the ASHA (2009) website Audiology and Speech-Language Pathology Associations Outside of the United States. (See References))
Organizations representing speech-language therapists/logopedists throughout the European Union may join the Standing Liaison Committee of Speech and Language Therapists/Logopedists in the European Union (CPOL). The CPOL was formed in 1988 to "harmonize" the profession in Europe. CPOL is comprised of 31 professional organizations representing 60,000 professionals in 28 European countries. CPOL focuses on education, legislation, exchange of scientific information, development of policies regarding speech therapy, creation of a Code of Ethics, and interaction among professionals.
The International Association of Logopedics and Phoniatrics (IALP) is the oldest organization that focuses on the study of and professional issues related to communication, hearing, and swallowing disorders. This organization promotes international networking and sharing of information through frequent meetings, symposia, and congresses and works with the United Nations and the World Health Organization. It also publishes a peer reviewed journal Folia Phoniatrica et Logopaedica and collaborates with the Center for International Rehabilitation Research Information and Exchange (CIRRIE) and the International Directory of Communication Disorders. (See Resources Section)
Communication Therapy International is another organization that was established by a group of British Speech and Language Therapists who had worked in countries where there were few or no communication disorders services. This group is devoted to sharing diagnostic and therapy ideas and resources with those in less developed countries. The organization meets yearly in the United Kingdom.
With increasing mobility across the world, SLPs may seek professional employment in countries other than the one in which they were originally trained and certified or licensed. Professionals relocating to another country must check with national, state, or provincial licensing agencies regarding their eligibility to practice. In 2009, however, the Multilateral Mutual Recognition Agreement went into effect whereby six countries mutually recognized each other's certification programs in speech-language pathology. These associations include the American Speech-Language-Hearing Association, the Canadian Association of Speech Language Pathologists and Audiologists, the Royal College of Speech and Language Therapists (United Kingdom), the Speech Pathology Association of Australia Limited, the Irish Association of Speech and Language Therapists, and the New Zealand Speech-Language Therapists Associations. The agreement provides a mechanism for applying for certification with any of the above associations but does not guarantee automatic reciprocal certification. Applicants may need to meet additional requirements for association certification or state licensure. For additional information check the ASHA website (ASHA, 2010c).
Speech-Language Pathology Assistants
Called speech-language pathology assistants, speech assistants, communication disorders assistants, communication aides, or paraprofessionals, these personnel may be used to extend the services of certified or licensed speech-language pathologists in the US and some other countries (e.g. Canada). According to the American Speech-Language-Hearing Association, SLP assistants are support personnel with academic and/or on the job training who carry out tasks "prescribed, directed and supervised by ASHA certified speech-language pathologists" (ASHA, 2010d). Speech assistants do not replace but extend services or provide operational (e.g. clerical, scheduling, record keeping, maintenance, and data collection) activities that allow certified or licensed professional to provide more in depth and efficient clinical services. Individual states in the US differ on the use of assistants, their professional and continuing education, and supervision requirements. Where used, speech assistants must be supervised closely. Reimbursement of speech assistant services varies by insurer. According to ASHA there are about 21 training programs in the United States, and there is no national certification or licensure for communication aides in the US. Again, according to ASHA (2010d) speech assistants in the US tend to be used more frequently in educational versus medical settings. Controversy continues in the US regarding the use of speech assistants as their employment may supplant the use of more highly trained, certified, or licensed speech-language pathologists and may confuse the public regarding who can provide qualified SLP services.
Future Issues Facing the Profession
Speech-language pathologists face numerous issues at the beginning of the 21st century. In the US emerging issues include how to assure access to affordable and adequate communication services from qualified professionals. Today's SLP must be prepared to offer services to caseloads from culturally and linguistically diverse populations. The global aging of the population means that there will be more older individuals who may have hearing, vision, and cognition changes and a variety of health and neurogenic disorders that may affect communication, cognition, and swallowing. These demographic changes indicate that SLPs will need new sets of skills from both their professional and continuing education.
Further, as developing countries begin to address the needs of their populations that have communication disorders, there will be a need for more professionals and better training in these countries. Increased international exchanges of information, data, and training will enhance all professionals. New models of clinical service delivery will need to be developed that fit the culture, languages, and rehabilitation services of each country.
Increasing emphasis on providing appropriate education for all students, including those with special needs, also indicates a growing role for SLPs in educational settings. Federal legislation in the US mandates a free, appropriate, and least restrictive education for all special needs students. Educational programming in the US also highlights the relationship between communication skills and literacy, thus increasing the role of SLPs in early intervention and literacy development programs.
Increase in communication services to adults and children requires adequate personal, public, and insurance funding to support programming in all types of practice settings. Third party payers, such as insurers and tax payers, demand that speech-language pathologists use methods that are derived from evidence based studies and document functional outcomes of services. This leads to the need for more research evidence that speech-therapy is effective and effacious. Research funding to support such studies is needed from national and other sources.
Another important issue that SLPs face is the need to work effectively with other professionals across settings. All clinicians must develop strategies for working collaboratively in interdisciplinary, multidisciplinary, and transdisciplinary teams. In some settings, SLPs may also supervise support personnel such as communication disorders assistants who extend their professional services.
Finally, the use of technology and telepractice in diagnostic and intervention services is just beginning. The use of technology, in particular the internet, offers speech-language pathologists the opportunity to transmit clinical information quickly to experts in various parts of the world. Such accessibility extends clinical knowledge and improves the quality of services. The use of technology and telepractice, however, must conform to standard ethical practice and confidentiality laws.
- American Speech-Language-Hearing Association
- American Speech-Language-Hearing Association Code of Ethics
- Center for International Rehabilitation Research Information and Exchange (CIRRIE)
- Communication Disorders Assistant Association of Canada
- Communication Therapy International
- Duchan J. (2008). Getting Here: A Short History of Speech Pathology in America
- International Association of Logopedics and Phoniatrics
- International Directory of Communication Disorders
- Speech Language Pathology Around the World
- Standing Liaison Committee of Speech and Language Therapists/Logopedists in the European Union (CPOL)