sound practice in action
Posted by Erin Smith on May 12, 2014 12:05 AM
I believe that clinical ‘instinct’ is developed through professional experience and reflective practice. Yes, I had acquired a great deal of knowledge during my graduate studies in speech-language pathology and by the time I graduated, I understood, at a theoretical level, stages of child development, fluency and head injuries — how and why “A” can lead to “B”. What I lacked, however, was the clinical practice and experience that would help me develop a clinical ‘instinct.”
As a new clinician, I knew that standardized testing was a critical part of the diagnostic process and so I relied heavily on those tests. Through reflective practice, I gained insight from the clinical experiences that I gained – and I slowly began to develop ‘clinician instincts.’ I began to master the art of providing informal assessments along with standardized assessments, and combining the results of the two to come to as clear and accurate a diagnosis possible. I learned through experience, to trust my ‘clinical instincts.’
I am going to share a recent clinical experience to demonstrate how developing, and trusting, our clinical instinct is important.
A family came to me for an assessment of their child’s speech and language skills. The child was three years and three months at the time of the assessment. The family’s first language was not English and as a result, I was relying a great deal on parental report and translation of test items on a standardized test.
The child initially sat on her mother’s lap and cried. After several minutes, she moved away from her mother and stood at the table but did not play with any of the toys or engage with me (even in non-speech play). Initially I had concerns around social communication skills (poor eye-contact, few attempts to initiate communicative interactions with her mother, inconsistent responses to requests).
However, as this child became more comfortable in the space, I observed her interacting and heard her speak to her mother in, what sounded to me, like short sentences. Her speech production included a limited variety of consonants and vowels. I asked her mother to interpret what was said. Mom indicated that she rarely understood what her daughter said and that she relied on visual and contextual cues to interpret her daughter’s message. At the end of the assessment I STRONGLY recommended a hearing test and that her daughter return for intervention to focus on articulation and further assessment of her daughter’s motor speech skills.
When the family returned for therapy, I had my SLP hat on, but I also remembered that a hearing test had been recommended.
I followed up with Mom and she reported that hearing testing was inconclusive. A copy of the hearing test results were obtained and the family was connected with our local infant hearing program audiologist for follow-up.
While waiting for the follow-up appointment, “speech” therapy began. My initial instincts, at the time of the assessment, told me that there was “something else” going on. Now I had to find the proof. Intervention was a combination of traditional speech therapy in an attempt to increase consonant and vowel production AND diagnostic therapy that included listening tasks. “Speech” therapy was successful when visual and tactile cues were used. However, when listening was the only mode of input, imitation was limited. I was able to gather functional information regarding speech sounds spanning a variety of frequencies.
This information was shared with the audiologist who completed follow-up testing. The results that she obtained were consistent with the less formal tasks that occurred during therapy sessions. The hearing test results were, again, inconclusive. However, based on the results from the audiologist and my input, enough information was available to make a recommendation for a sedated ABR. At this point, we are waiting for that appointment to happen.
My experience with this family reminded me how important it is to follow your clinical instincts and demonstrate to the client/family evidence that proves the need for an alternative diagnostic process or intervention.
• The child’s speech production had perceptual characteristics similar to individuals with hearing loss.
• limited variety of consonant sounds (inconsistent substitutions)
• limited variety of vowel sounds (inconsistent substitutions)
• relying on visual and tactile cues to approximate speech targets
• child relying on increased visual cues for comprehension
• no response to high frequency speech sounds during Ling six-sound test
• difficulty discriminating between minimal pairs that included mid-high frequency sounds
• Audiology appointment
As an SLP I often work with children who have ‘no known reason’ for a communication concern. As a result, when I need to have a conversation with a family about other concerns it can be difficult. It helps for me to have specific evidence to share with the family that leads me to my decision. For example, in the case presented above, I was able to map the child’s speech errors onto an audiogram and demonstrate consistent relationships between speech production and potential hearing concerns.
Our time with families can be limited and conversations like this can be very difficult. When I have a ‘feeling’ that there is more to the client’s clinical presentation, I find clinical confidence when I have proof to back up that ‘feeling’.
When we support our recommendations with solid evidence, it can move a family forward toward appropriate assessments and intervention(s). This ultimately leads the professionals and the families in the direction that they need to go in order to help the clients reach their potential.
Part 2 of Erin’s blog entitled ‘Trust your instinct… and support it with evidence!‘ will follow. Read about the outcomes of the case study presented in this blog.
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KAREN MACIVER LUX