After reading this chapter, students will be able to
- Discuss the role of evidence-based practice in clinical work
- Describe the use of interprofessional practice
- List the elements that go into making clinical decisions
- Discuss how their personal values and experiences led them to a career in communication disorders
Jamie was an audiologist who was asked to screen a student named Mari entering the third grade of Bridgerton school district as a new immigrant from Guatemala. The teacher reported that Mari didn’t speak in school and thought her hearing should be checked. Jamie gave her a routine screening, and Mari failed at all frequencies. A full audiological assessment showed that Mari was profoundly deaf in both ears. When questioned, Mari’s mother, who spoke no English, managed to convey to Jamie (who had limited Spanish proficiency) that Mari had never spoken, never been to school before, and communicated mostly through gestures. Her mother reported that Mari was able to perform activities of daily living, such as dressing, eating, toileting, and helping around the home as would be expected of a child her age. Jamie realized that she had met a unique student, one with essentially normal cognition but no language as a result of her inability to hear spoken language and her lack of education or exposure to any other form of language. Jamie had never encountered a client like this, despite being a practicing audiologist with over 10 years’ experience. But Jamie had learned about evidence-based practice as a graduate student and knew the procedures for investigating what was known about clients with rare or unusual problems. With help from the American Speech-Language-Hearing Association (ASHA) Practice Portal, journal articles provided by the local university library, and consultation with some of the faculty there, Jamie researched what was known about children similar to Mari and what techniques had been tried to provide access to a linguistic system for them. She assembled an evidence base for providing first language instruction to children with profound hearing loss after the age of 5. She analyzed the evidence and discussed her findings with colleagues. She consulted with Mari’s teacher, speech-language pathologist (SLP), and parents to discover an acceptable intervention program for Mari. Although Jamie favored providing a cochlear implant, Mari’s family had no health insurance and in any case did not want to subject her to surgery. They felt she was okay as she was and did not feel she needed to be “fixed” with surgery. Jamie ultimately came to accept the parents’ position, at least for the present, and worked with the teacher and SLP to provide intensive sign language instruction through the state’s Deaf Education Collaborative, because research supported this suggestion. It was difficult for Jamie to give up the idea of fighting for an implant for Mari, but the results of the evidence search indicated that deaf children can thrive with sign language when the context is supportive. Plus, Jamie had worked closely with the Deaf Education team often in the past and was impressed with their skills in helping children and their families learn signs. Jamie realized that it was important to rely both on evidence and on the values of parents when making a clinical decision.
CLINICAL ART AND SCIENCE
This kind of dilemma will be discussed in more detail in Chapter 3
. What’s important to take away from this case is the knowledge that there may be more than one correct answer to a clinical problem. A second important point is that Jamie’s experience with interprofessional practice
enabled a broader set of perspectives and approaches to be brought to the clinical issue and enhanced the team’s ability to serve the client’s needs more effectively and sensitively.
To offer a less dramatic example of the decisions often faced in clinical practice:
I was once supervising a first-term student clinician named Jane. Jane was working on articulation with Mike, a pixie-faced 3-year-old with almost completely unintelligible speech. Mike had a lot to say, but Jane could understand almost none of it. He was trying to tell her something about the toy dinosaur he had brought from home and, try as she might, she just was not getting it. After attempting three or four times to get the same message across, poor little Mike burst into tears of frustration. Jane was, naturally, taken aback. Sitting behind the mirror, I saw Jane trying to talk the little boy into feeling better. Finally, unable to contain my own distress at seeing Mike so miserable, I went into the room and held him, rocking him until he finished crying. Mike was soon able to resume his work. In our conference following this incident, Jane remarked, “I was so glad when you came in and held him. I didn’t think I was allowed to do that; it didn’t seem like the kind of thing a clinician is supposed to do.”
That is what this book is about—the kinds of things that clinicians are supposed to do. These anecdotes highlight something essential about clinical practice: even though clinicians need high levels of technical training and a deep understanding of evidence-based practice, it is always important to remember that our clients are first and foremost people—people with complicated, sometimes conflicting feelings and needs; people who sometimes do not use their clinical time efficiently; people whose motivation to learn better communication skills is sometimes overwhelmed by other emotions, by the broader circumstances of their lives, or by the values with which they grew up. This means that a good clinician must be part scientist and also part humanist.
But, you may be thinking, how can I learn to be a scientist, a humanist, and an expert on normal and disordered communication before I see my first client next semester? Fortunately for all of us, there is one more thing that every clinician needs to be, and that is a human being. Neither your supervisor, your client, nor anyone else will expect you to be a fully developed clinician your first term. With your first client, and probably with some of your later ones, too, you will make mistakes. Like any other human being, you will have to make amends for these mistakes, try to learn from them, and do better the next time. Competent clinicians at all stages of their careers recognize and learn from their own mistakes. Still, the purpose of this book is to help you begin to make the transition from a student of communication disorders to a speech, language, and/or hearing clinician.
Being a clinician entails some qualities that probably cannot be taught by your professors. These are the qualities we identify with the humanist, and to some extent they arise out of your own beliefs, needs, desires, and personality. It is these qualities that probably brought you to consider a career in communication disorders. These qualities may include:
- A desire to help others
- Strengths in social interactions
- Enjoyment of close contact with people
- Strong communication skills
- The ability to take pleasure in just talking
- An interest in the various processes by which communication takes place
- A level of comfort with people with disabilities
These qualities are not present in everyone, but as a starting point for becoming a clinician, they are essential. As you must know by now, although these qualities contribute to making you a good clinician, more is needed. You need an in-depth knowledge of the normal processes and development of communication and the characteristics, causes, and correlates of the various kinds of communication disorders. You need to understand how to evaluate evidence of the effectiveness of the approaches you use. You also need knowledge of the information introduced in this book. Here you will learn about the kinds of behaviors and activities in which a clinician engages and about the contexts in which these behaviors and activities take place. The goal is that when you are through, you will have a better sense of what it is a clinician does; where he or she does it; and what general principles of science, ethics, public policy, cultural sensitivity, and respect for clients and families guide our behaviors and activities.
SCOPE OF PRACTICE
What do SLPs and audiologists do? Where do they do it? With and for whom? Why do they take this approach and not that one? These are the questions that define our scope of practice. SLPs and audiologists work with clients from birth through old age. Audiologists screen newborns for hearing loss; SLPs work with premature infants to develop feeding, swallowing, and early parent–child communication skills. Audiologists and SLPs work with infants and toddlers with a variety of developmental disabilities, including hearing impairment, intellectual disability, autism, congenital anomalies such as cleft palate, congenital disorders such as cerebral palsy or fetal alcohol spectrum disorders, and feeding and swallowing problems. We work with children with cochlear implants. Clinicians who work with very young children are often engaged in secondary prevention; that is, assessment and intervention aimed at limiting the impact of disorders on communication and development. SLPs and audiologists also work with preschool children who have these kinds of problems in speech, hearing, feeding, and/or language that surface in early childhood. These include articulation disorders, fluency disorders, hearing impairments, and language disorders. We also, unfortunately, see children in this age range whose communication has been affected by abuse or neglect or whose development has been influenced by parental substance abuse.
SLPs and audiologists often work with school-age populations. In this age range, we see children such as those already described, as well as children who injure their voices through inappropriate use, have trouble producing fluent speech, or endanger their hearing through noise exposure. A large part of an SLP’s practice in schools deals with students who have language-based learning disorders that affect their ability to master the academic curriculum. These students require support to enhance their language so they can use it more effectively to succeed in school. School-based SLPs and audiologists provide communication intervention within the context of academic instruction. SLPs also sometimes provide management for students with emotional or social disorders that affect communication, such as autism spectrum disorder, selective mutism, or children diagnosed with mental illness.
Many SLPs and audiologists work with adult clients as well. Adults with various developmental disabilities continue to require the services of communication specialists. Some young and middle-aged adults experience communication disabilities as a result of illnesses or traumatic brain injury. Older adults are especially vulnerable to acquiring communication disorders. Many audiologists work with older adults experiencing age-related hearing loss, or presbycusis. SLPs serve older clients who lose speech and language skills due to neurological diseases, such as strokes, Parkinson’s disease, and amyotrophic lateral sclerosis (Lou Gehrig disease).
Best practice for clients all along the spectrum of development includes close collaboration with their families and with other professionals involved in their care. When a client receives services from several professionals, it serves the client best if these professionals are aware of each other’s goals and methods and can coordinate services for the client. Many professionals collaborate to help deliver services in a more integrated manner, so the client receives consistent feedback and reinforcement and has more opportunities for generalization. Clinical practice in communication disorders often involves interprofessional collaboration with teachers and special educators; physical and occupational therapists; psychologists and social workers; recreational and vocational counselors; nurses and physicians; as well as with the staff of schools, residential centers, group homes, rehabilitation facilities, hospitals, and skilled nursing facilities.
SCOPE OF TEXT
This book introduces the processes, settings, and issues involved in clinical practice in communication disorders. Chapter 2
discusses the codes of ethics disseminated by ASHA and the American Academy of Audiology (AAA). These codes are central to the practice of our professions because they lay out our obligations to our clients, our payers, and our colleagues and provide guidelines to help us in making sometimes difficult ethical decisions. Chapter 3
addresses the issue of evidence-based practice and the steps a clinician can take to find support for specific assessment protocols and intervention strategies. Chapter 4