‘Don't say “fis” say “fish” ’, ‘I said “fis”’: ethical considerations in therapy to change child speech

Background

Historically, assessment of child speech has focused on transcription and analysis of speech sound production with no exploration of the child's own perception of his or her speech. This article explores the possibility that whilst children with speech ‘difficulties’ may be aware that ‘talking to people’ is problematic, they may not be aware that the reason for their communication difficulty is that their speech is unclear. Similarly, in a therapy context, the child's own appreciation of the purpose and progress of therapy has not been explored. Given the current concern for child well-being, particularly in educational settings, it is timely to examine the premise that all children with speech difficulties are consciously aware that their speech is different, that they want to change the way they talk and that they welcome help to improve their speech.

Aims

This overview of a child's own perception of his or her ‘disordered’ speech aims to bring the child's perspective clearly into focus. Long-held assumptions that children are aware of their speech differences and seek to change them are revisited, and consideration is given to the possibility that young children with speech disorders don't perceive the difference between adult pronunciations and their own. An ethical perspective of engaging young children in activities to change the way they talk before they have developed an appreciation that their pronunciation is different from an adult model is presented and considered. Readers will gain new insights into a child's perspective of not being understood and of being confused by efforts to help them to speak more clearly when their own perception is that their speech already matches the adult pronunciation. Clinicians will come to appreciate that strategies to ‘help’ children with their speech may feel confusing and even distressing to the child. Given the likelihood that children with SSD/D have little or no awareness of their mispronunciations, a case is made for a less corrective, directive style of therapy and for more facilitative, non-corrective therapy.

Method

Childhood experiences of growing up with speech sound difficulties are considered through child-focused interpretation of clinical video data and relevant literature. Review of a small selection of parent-consented videos originally collected for clinical or audit purposes prompted reflection on the child's perspective of assessment and therapy. In addition, adult reflections on their childhood experiences of speech problems in different contexts and at different ages were considered. Principles of ethical practice provided a framework for conceptualising ways in which well-intentioned therapy might provoke imperceptible emotional harm. Strategies are proposed for ensuring that ‘problem-based’ therapy is child-focussed, promotes autonomy and positive self-esteem and minimises the risk of imperceptible emotional harm.

Main Contribution

This discussion article highlights a gap in clinicians’ recognition that children in early and middle childhood (2-7 years) may be unaware of their specific speech differences and that they are likely to be confused by therapy activities that require them to change the way they talk. An ethical perspective introduces the possibility that, without some child-focused explanation about the reason for therapy, intervention might cause distress, which children are likely to suppress, and, in some cases, long-term therapy may cause emotional harm. Strategies based on ethical principles are proposed for communicating with children about speech and for introducing ‘new ways’ to pronounce sounds. Development of a training route for equipping speech and language therapists (SLTs) to adopt a non-directive, collaborative style is recommended.

Conclusion

From an ethical perspective, this discussion paper introduces the possibility that well-intentioned therapy aimed at changing a child's speech could inadvertently cause emotional harm. It proposes that subtle adjustments to therapy style may elicit new sounds without conscious effort from the child, thereby reducing risks to emotional well-being such as fear of failure and confusion when new productions are deemed to be ‘right’ but feel wrong to the child. Collaboration between SLT, parents, school and, where possible, ELSA (Emotional Literacy Support Assistant) would reduce the risk of unintended harm that might be caused by practice-based therapy.

WHAT THIS PAPER ADDS

What is already known on this subject

The question as to whether or not children are able to perceive mismatches between their own mispronunciations and their intended production has, to date, been sadly overlooked. This is reflected in the absence of any reference to the child's perspective in routine speech assessments. Existing literature indicates that children have little or no awareness that their speech is distinctive or in what ways it needs to be changed. Hence, it is quite possible that a proportion of children undergoing therapy are confused and could be distressed by therapy which seeks to change the way they talk.

What this study adds to existing knowledge

By viewing therapy to change and ‘improve’ a child's speech, from the child's perspective, this article invites clinicians to question their assumptions that children will appreciate ‘help’ to speak more clearly. Attention is drawn to the risk that therapy might provoke an accumulation of unexpressed negative emotions which could lead to emotional harm. Strategies are suggested for exploring a child's perspective of their speech and for creating opportunities for collaborative therapy planning in the hope that therapy might boost, rather than erode, a child's self-esteem.

What are the potential or actual clinical implications of this work?

Increased awareness of the risk that children who are compliant with therapy for speech ‘differences’ may experience emotions such as confusion, anger or general distress during therapy might lead to adjustments in therapy style. It is proposed that shared exploration of a child's speech patterns, with the child, at assessment, followed by collaborative therapy planning and child-focussed progress reviews, might enrich both therapist and child experiences of therapy for speech differences in childhood.