INT J LANG COMMUN DISORD, SEPTEMBER–OCTOBER 2013,

VOL. 48, NO. 5, 486–496

Discussion
Child speech, language and communication need re-examined in a
public health context: a new direction for the speech and language
therapy profession
James Law†, Sheena Reilly‡§ and Pamela C. Snow¶
†Speech and Language Sciences, Newcastle University, Newcastle upon Tyne, UK
‡University of Melbourne, Melbourne, VIC, Australia
§Murdoch Children’s Research Institute, Australia
¶School of Psychology and Psychiatry, Monash University, Melbourne, VIC, Australia
(Received April 2012; accepted April 2013)

Abstract
Background: Historically speech and language therapy services for children have been framed within a rehabilitative
framework with explicit assumptions made about providing therapy to individuals. While this is clearly important
in many cases, we argue that this model needs revisiting for a number of reasons. First, our understanding of the
nature of disability, and therefore communication disabilities, has changed over the past century. Second, there is
an increasing understanding of the impact that the social gradient has on early communication difficulties. Finally,
understanding how these factors interact with one other and have an impact across the life course remains poorly
understood.
Aims: To describe the public health paradigm and explore its implications for speech and language therapy with
children.
Methods & Procedures: We test the application of public health methodologies to speech and language therapy
services by looking at four dimensions of service delivery: (1) the uptake of services and whether those children who
need services receive them; (2) the development of universal prevention services in relation to social disadvantage;
(3) the risk of over-interpreting co-morbidity from clinical samples; and (4) the overlap between communicative
competence and mental health.
Outcomes & Conclusions: It is concluded that there is a strong case for speech and language therapy services
to be reconceptualized to respond to the needs of the whole population and according to socially determined
needs, focusing on primary prevention. This is not to disregard individual need, but to highlight the needs of the
population as a whole. Although the socio-political context is different between countries, we maintain that this is
relevant wherever speech and language therapists have a responsibility for covering whole populations. Finally, we
recommend that speech and language therapy services be conceptualized within the framework laid down in The
Ottawa Charter for Health Promotion.

Keywords: speech and language therapy, child, public health.

What this paper adds?

What is already known on the subject?
Historically speech and language therapists working with children have tended to adopt a ‘clinical’ approach to case
management with children referred and diagnosed with speech and/or language disorders. Initiatives such as Sure
Start in the UK, which have emphasized the need to adopt a population approach, have led some therapists to
change their practice, but as Sure Start is rolled back, there is a danger that population-based approaches may not be
sustainable without a public health framework around them.

Address correspondence to: James Law, Institute of Health and Society and School of Education, Communication and Language Sciences,
Newcastle University, Victoria Road, Newcastle upon Tyne, NE1 7RU, UK; e-mail: j.law@ncl.ac.uk
International Journal of Language & Communication Disorders
ISSN 1368-2822 print/ISSN 1460-6984 online  C 2013 Royal College of Speech and Language Therapists

DOI: 10.1111/1460-6984.12027
Child speech, language and communication need in the context of public health
What this paper adds?
This paper identifies the key characteristics of a public health framework. We suggest that speech and language
therapy services for children need to be grounded in public health principles if they are to meet the needs of the
populations they service at both prevention and intervention levels. We propose that speech and language therapy
services be reconceptualized to reflect the recommendations of the Ottawa Charter for Health Promotion.
Introduction
Historically, the speech and language therapy profession
has operated within what might be termed a ‘medical
model’ of disability (Llewellyn and Hogan 2000), fo-
cusing on diagnosing and remediating specific problems
by providing an individualized therapeutic service. Such
services are responsive to the needs of those who present
at clinics, but not necessarily to the wider population.
The main exception to this has been the role that speech
and language therapists (SLTs) have played in Sure Start
since the inception in 1999 in the UK (Sawyet et al.
2008). In this paper, we argue that a number of re-
cent developments have had such a profound impact
on the context in which children’s SLT services are pro-
vided that it is time to re-examine the positioning of the
profession and aspects of the evidence base that under-
pins it. We propose a shift in emphasis, analogous to
that in other areas of healthcare, from a clinical ‘within-
child’ focus to one grounded in public health principles
(Israel et al. 1998), and illustrate the application of this
thinking with respect to children with speech, language
and communication needs (SLCN1 ). This issue is es-
pecially relevant in the UK with the prioritization of
public health services (HM Government 2010), but it
is also pertinent in other countries where services are
publicly funded, e.g. within the school system in the
United States (Logemann and Baum 1998). Of course,
this is not a new discourse. As early as the 1972 Enquiry
into Speech Therapy, Randolph Quirk recommended
that speech therapy, unlike many other clinical services,
should be seen as a universal service (Quirk 1972). With
the exception of a few attempts to capture and describe
the populations that it serves, however (e.g. Enderby and
Philipp 1986), the profession has tended to emphasize
the individual with a disorder at the expense of under-
standing the broader population perspective and social
factors that drive communication competence (Snow
2009).
1
‘Speech, language and communication need (SLCN)’ is the term
first coined in the Bercow Review (Bercow 2008) to refer to the
whole population of children with communication needs, whether
these relate to speech, language, fluency or any other aspect of com-
munication.
487
What is ‘public health’?
The Faculty of Public Health in the UK defines public
health as:
The science and art of promoting and protecting health
and well-being, preventing ill health and prolonging life
through the organised efforts of society. There are three
domains of public health: health improvement (includ-
ing people’s lifestyles as well as inequalities in health
and the wider social influences of health), health pro-
tection (including infectious diseases, environmental
hazards and emergency preparedness) and health ser-
vices (including service planning, efficiency, audit and
evaluation. (HM Government 2010: 11)
Underpinning public health approaches is the
assumption that while some causes of ill-health/
disability may lie within the individual (e.g. inherited
predispositions, physical or sensory disabilities), many
lie within socio-economic circumstances and the solu-
tions to many problems need to be socially, rather than
individually, determined. Increasingly, researchers and
clinicians have moved away from searching for single
causes to try to explain childhood conditions. Instead
they focus on the relations between factors, such as an in-
dividual’s genes and the early environment. While genes
provide a blueprint for children’s health and well-being,
multiple environmental factors can influence develop-
mental pathways.
Central to public health thinking is an understand-
ing of the social and environmental determinants of
the processes that underpin health and the need for
equity in access to both life opportunities and health
services. This begins at the policy level and includes
a range of strategies from the simple dissemination of
positive health messages in the community via health
education, to whole-of-government (e.g. health, educa-
tion, transport, employment, housing) policy and prac-
tice approaches to health promotion, targeting drivers
of health inequity. Public health approaches also en-
compass systematic data gathering about populations
through surveillance and screening for conditions that
can be effectively treated if detected early. In developed
nations, they also increasingly include chronic disease
management in the community to improve the inter-
face between primary, secondary and tertiary health
488
services (i.e. ranging from first-contact services with gen-
eral practitioners through to referrals to specialists and
finally hospitalization). Two types of public health ap-
proaches are commonly identified in the literature. ‘Old’
public health (Baum 2002) was concerned with air and
water quality, adequate nutrition, and ensuring people
are not living in squalor, at high risk of contracting dis-
eases that are now largely prevented, in the developed
world at least, through immunization programmes. In
contrast, ‘new’ public health (Baum 2002) concentrates
on preventable factors such as economic well-being,
lifestyle and environmental exposures. ‘New’ public
health is also concerned with the impact that factors such
as family stress, inadequate economic and psychosocial
resources, geographical location, ethnicity and socio-
economic status have on different populations’ access to
services. While some factors such as poor mental health
or childhood accidents may be considered outcomes of
early adverse environmental exposures, others, such as
smoking or alcohol abuse, might be both outcomes
of disadvantage and determinants of further adversity
across the lifespan (Baum 2002). Key to this use of the
term are social determinants of health or ‘factors charac-
terizing the environments that individuals are “exposed”
to and that can influence lifelong developmental and
health outcomes’ (Maggi et al. 2010). Social determi-
nants create a ‘health gradient’ which results in poorer
health for those with the poorest economic circum-
stances and this gradient operates throughout society
(Fosse 2011).
Public health interventions are often described as
being primary, secondary or tertiary levels of preven-
tion. Primary prevention activities are directed at the
general population and attempt to stop early speech
and language difficulties occurring. All members of the
community have access to and may benefit from these
services. Primary prevention activities with a universal
focus seek to raise the awareness of the general public,
service providers, and decision-makers about the scope
and problems associated with early speech and language
difficulties. Secondary prevention activities occur with
populations identified as being at risk for speech and
language difficulties because of marked social disad-
vantage, parental risk factors, family history, failing a
screening procedure, etc. The aim here is to provide
treatment for the difficulties and thereby facilitate the
child to have speech and language skills which are in-
distinguishable from those of their peers. Tertiary pre-
vention activities focus on families where the child’s
difficulties are persistent and have not responded to in-
tervention. Here the aim is to reduce the negative effects
of the speech and language difficulty rather than re-
move it altogether (adapted from guidance from the US
Department of Health & Human Services (USDHSS)
2004).
James Law et al.
Key to understanding this framework for prevention
is that all interventions are potentially preventative, even
though what is to be prevented may change.
The changing nature of communication
disabilities in society
It is becoming increasingly clear that SLCN can be a
lifelong phenomenon affecting all aspects of social in-
clusion, including literacy, mental health and the acqui-
sition of marketable employment skills in an increasingly
skilled workforce (Law 2011, Snow and Powell 2004).
The point is not that this is a new phenomenon per se,
but that understandings of what constitutes a disabil-
ity have changed over the past century (Ruben 2000).
While developed societies that exercise a strong social re-
sponsibility for their citizens have become more inclusive
in many ways (e.g. through universal access to general
practitioners and other elements of primary care), they
have arguably become less inclusive when it comes to
those with communication disability. The more sophis-
ticated, the better educated and the more automated,
or digitalized, the society becomes, the greater the shift
from blue collar manual employment towards white col-
lar ‘communication focused’ jobs, something which cre-
ates particular challenges for the less advantaged, partic-
ularly in times of economic downturn. Young people
are, by definition, ‘less advantaged’ in the job market
because they are less likely than older workers to have
skills or experience, and are thus more vulnerable to
economic exigencies (Foundation for Young Australians
2011). This makes it difficult for a young person with
any sort of communication disability to break into and
progress within the job market (Ruben 2000). Ruben
(2000) has argued that as a result of the ‘shift from
brawn to brain’, a young person with a communication
difficulty has become more vulnerable than one with a
physical disability, observing that:
During most of human history a person with a com-
munication disorder was not thought of as ‘disabled’.
The shepherds, seamstresses, plowmen, and spinners of
the past did not require optimal communication skills
to be productive members of their society, as they pri-
marily depended on their manual abilities. Today a fine
high-school athlete—a great ‘physical specimen’—who
has no job and suffers from poor communication skills
is not unemployed, but, for the most part, unemploy-
able. On the other hand, a paraplegic in a wheel chair
with good communication skills can earn a good living
and add to the wealth of the society. For now and into
the 21st century, the paraplegic is more ‘fit’ than the
athlete with communication deficits. (p. 243)
Acknowledgement of the significance of communica-
tion competence is also reflected in the recently released
Industry Skills Council of Australia report No More
Child speech, language and communication need in the context of public health
Excuses (2011), in which Australian Federal Member
of Parliament John Dawkins states: ‘There is undeni-
able evidence to demonstrate that poor communication
skills adversely affect productivity in the workplace and
productivity suffers, as does our global competitiveness’
(p. 3).
Testing the application of public health
methodologies to speech and language therapy
In order to explore the potential application of pub-
lic health principles to SLCN, we consider four areas
relevant to public health, namely: (1) the uptake of ser-
vices and whether those children who need services re-
ceive them; (2) the development of universal prevention
services in relation to social disadvantage; (3) the risk
of over-interpreting co-morbidity from clinical samples;
and (4) the overlap between communicative competence
and mental health.
The uptake of services
Key to our understanding of SLCN within the public
health context is an awareness of need in the population.
The definition of what constitutes disability, and there-
fore SLCN, has evolved over a number of years. This has
resulted in changes to the profiles of children considered
to be in need of intervention and the development of
services to meet these needs.
While the early focus on, for example, disordered
speech and stammering has continued, there has been an
increasing need to manage disorders of language learn-
ing, and more recently pragmatic disorders and disorders
associated with social, emotional and behavioural diffi-
culties. Relatively little is known about how populations
use services, because this information is often simply
not available. To our knowledge only two population
studies have examined help-seeking behaviour and these
suggested that only one-third of those identified with
difficulties had sought or been referred for help from an
SLT. Tomblin et al. (1997) asked the parents of children
participating in their epidemiological study if they had
been told that their child had a speech and language
problem and, if so, whether the child received or was re-
ceiving any help. Of the 216 children identified to have
specific language impairment (SLI) in Tomblin et al.’s
study, only 29% had been referred to clinical services.
The authors reported that there were distinct patterns
of service use varying as a function of SLCN type. In a
related study (Zhang and Tomblin 2000), some of the
factors that might explain help seeking behaviour such as
sex, ethnicity, neighbourhood, income level, geographic
location (rural/urban, etc.) were explored. An Australian
study found exactly the same proportion of 4-year-old
489
children with low language skills accessing SLT services
(Skeat et al. 2010).
From the clinician’s perspective, this means that two-
thirds of children with SLCN do not present for help. It
is highly unlikely that those presenting to clinics will be
representative of the population with communication
impairments as a whole, and this means that the results
of clinical research studies should only be generalized
back to that sample (i.e. the clinical sample and not
the whole population from which they are derived). Of
course, it may be argued that children in need of ser-
vices will be identified in schools by teachers, but such
evidence as exists suggests that school teachers do not
consistently identify children with SLCN (e.g. Antoni-
azzi et al. 2010). Indeed, recent analysis of national data
in England suggests that only 2.5% of children are iden-
tified with speech and language communication needs
at 7 years of age (one-third of the figure identified by
Tomblin et al.’s, 1997, 7.4% at school entry) and that
this falls rapidly to 0.5% by the time children reach the
end of primary school (Meschi and Vignoles 2010).
It is also important to consider issues associated with
equity of access to services. Significantly, given the above
discussion, little has been published on this topic in the
field of speech and language sciences, although a re-
cent paper has suggested that 98% of rural districts in
New South Wales and Victoria in Australia were not
adequately covered by speech and language pathology
services (Verdon et al. 2011). This finding is consis-
tent with the evidence that access to services and health
outcomes sit on a gradient that is both socially and geo-
graphically determined (Maggi et al. 2010). Those who
are more disadvantaged tend to have poorer health and
educational outcomes (Marmot 2010) and this is likely
to be exacerbated unless educational and health services
are able to compensate in some way for this gradient. In
reality those who are most disadvantaged often receive
fewer services (Smith et al. 2008). Perhaps symptomatic
of the historical focus on disorder, relatively little has
been written about equity of access which is specific to
SLT in any country. The fact that we know so little
about this is issue is almost certainly an indicator in
itself that more needs to be done to ‘know’ our popula-
tions and assess the extent to which they are adequately
serviced.
Universal prevention services in relation to social
disadvantage
There is strong consensus that early intervention can
be both developmentally efficacious and cost-effective
(Heckman and Carneiro 2003). Indeed, early language
and other socio-cognitive skills and their proxy ‘school
readiness’ have become the focus of much of this early
490
intervention and are now seen as key indicators of dis-
advantage (Field 2010, Marmot 2010). That said, it is
important to stress that early preventative work may not
always be the panacea that it is sometimes assumed to be.
The paradox is that services are designed to address, and
funding models facilitate, the traditional remedial mod-
els of service delivery. Underpinning this is the finding
that socially disadvantaged children ‘start from behind’
with respect to communication competence and that
their subsequent experiences only serve to exacerbate
this disadvantage (Law et al. 2009). Inevitably, of course,
given the nature of some communication impairments,
some children will experience lasting SLCN, even if their
psychosocial disadvantage can be ameliorated.
Like early childhood educators and others, SLTs of-
ten stress the need to ‘get in early’ and many have devel-
oped interventions to do just this, often but not always
associated with the most substantive preventative invest-
ments, namely Head Start in the United States (Barnett
and Hustedt 2005), Sure Start in the UK (Melhuish
et al. 2010), and the Pathways to Prevention Project in
Australia (Homel et al. 2006). Of these, the first did not
specifically focus on early language, although the evalua-
tions often included language measures. By contrast the
focus on early language skills and language outcomes
at 2 years was a feature of the Sure Start programme.
An audit repeated on three occasions over a 4-year pe-
riod using the Sure Start Speech and Language Measure
(SSLM), which is a modification of the MacArthur–
Bates Communicative Development Inventories (Fen-
son et al. 2007), at 2 years suggested improvements
in child performance over a 4-year period (Harris
et al. 2005), while the results of the quasi-experimental
evaluation study using a language assessment at 3 years
indicated positive results for the children of ‘non-teen’
mothers (Melhuish et al. 2010). Similarly, Homel et al.
(2006) reported significant gains in communication and
behavioural outcomes for children transitioning from
preschool to school, between 5 and 6 years of age in
a socio-economically disadvantaged region of Queens-
land, Australia, as a result of the Pathways to Preven-
tion programme. These authors also noted that the cost
of this preventative intervention compared favourably
with the cost of state-funded remedial services targeted
at similar outcomes at a later developmental period.
Many SLTs responded to Sure Start by adapting their
model of intervention to what might be termed a public
health model, striving to understand their population,
reaching out to subpopulations that might not other-
wise access clinical services, and working in settings not
traditionally associated with SLT (e.g. supermarkets and
high street venues). Perhaps inevitably this led to aware-
ness that there are far more children with low language
skills than many had anticipated (Locke et al. 2002).
SLT services were expanded in many areas in the UK
James Law et al.
to respond to Sure Start and subsequently many SLTs
have continued to see their role in changing the child’s
communication environment as a key element of their
practice (Dockrell et al. 2012). Similar in some ways
to the US ‘Response to Intervention’ model, such ap-
proaches have much to recommend them, although they
need rigorous evaluation of the outcomes for the chil-
dren concerned (Ehren and Nelson 2005).
The risks of over-interpreting co-morbidity from
clinical samples
A public health or population approach is likely to
have a bearing on our interpretation of research. Many
health ‘conditions’ occur alongside secondary or co-
morbid conditions, but restricting the study of such
conditions in referred, clinical populations can distort
the interpretation of these relationships. For example,
stammering (stuttering in the United States and Aus-
tralia) is a relatively common SLCN, affecting between
5% and 11% of preschoolers and 1% of adults (Craig
and Tran 2005, Craig et al. 2002, Reilly et al. 2009).
Examination of clinical populations has suggested that
children who stammered were more shy and withdrawn
than non-affected peers, and that childhood tempera-
ment characteristics might be precursors to the anxiety
and social phobia observed in adolescence and adult-
hood (Iverach et al. 2009a, 2009b). These assumptions
were questioned recently following publication of pop-
ulation data from a community cohort of children re-
cruited in infancy. Measures were taken prior to stam-
mering onset in infancy and then at regular intervals
throughout the early preschool years. First, the authors
reported a much higher cumulative incidence of stam-
mering onset of 11% by 4 years of age (Reilly et al.
2009). Second, stammering onset in the first 4 years
of life was not associated with significant co-morbidity,
in either the domain of communication (e.g. speech
and language problems) or general development (e.g.
social, emotional and behavioural problems). With re-
spect to temperament, children with stammering onset
were not more shy or withdrawn and on temperamental
dimensions such as ‘approach’ and ‘easy–difficult’ they
did not differ from a large typically developing control
group. Not only was stammering onset by 4 years not
associated with poorer outcomes, but it was positively
associated with better outcomes at this young age. It is
tempting therefore to conclude that at 4 years having
stammered seems rather a good thing because it makes
you smarter, gives you better language scores, and bet-
ter social and preschool skills (Reilly et al. in press).
No one, however, who has watched an adolescent or
adult struggle to communicate as a result of stammering
would think the condition desirable. Population studies
Child speech, language and communication need in the context of public health
identify many more mild cases and, as indicated above,
it is clear that many individuals do not present for a
clinical diagnosis or to request treatment. Could it be
possible that the absence of co-morbidity in population
studies is explained by the relative over-representation
of milder cases? That is, perhaps only those with devel-
oping co-morbidity attend clinic? Alternatively, perhaps
the presence of impairment does not, in itself, drive indi-
viduals to seek services, unless there is an accompanying
limitation in activity or participation (World Health
Organization (WHO), Workgroup for Development of
Version of ICF for Children & Youth 2007). Whatever
the answers to these questions, detailed epidemiological
data are key to the provision of effective and equitable
services.
The overlap between communicative competence
and mental health
The World Health Organization (WHO) defines men-
tal health as ‘a state of well-being in which the individual
realizes his or her own abilities, can cope with the normal
stresses of life, can work productively and fruitfully, and
is able to make a contribution to his or her community’
(WHO, Workgroup for Development of Version of ICF
for Children & Youth 2007). According to the Victo-
rian Health Promotion Foundation (VicHealth 2005),
determinants of mental health include: social inclusion,
freedom from discrimination and violence, and access
to economic resources. Clearly, communicative compe-
tence is central to these ideals because it facilitates family
and peer relations, and leads to marketable employment
skills and social engagement. Most everyday tasks have a
communication element, either at their core (e.g. dealing
with interpersonal conflict) or as part of their solution
(e.g. having to ‘log’ a problem on a website in order to re-
ceive assistance). Communicative competence occupies
a unique place in the lives of children, as it is of interest
both as a predictor variable and an outcome variable with
respect to mental health (i.e. language competence in
early life fosters social competence) and the transition
to literacy, and language competence in adolescence re-
flects a range of pro-language protective factors in the
early years (Snow 2009). Behaviour problems in early
life (e.g. oppositional defiant disorder and conduct dis-
order) are in themselves serious mental health problems,
as evidenced by their inclusion in the Diagnostic and
Statistical Manual (DSM-IV-TR) of the American Psy-
chiatric Association (APA) (2002), but they may also
‘blind-side’ adults in the child’s world about other de-
velopmental struggles the child is experiencing. What
manifests in the classroom as a ‘behaviour problem’ (e.g.
failure to negotiate appropriately with other children
around access to equipment) may in fact be more ap-
491
propriately described as a skill deficit, i.e. an inadequate
repertoire of socially sanctioned linguistic skills to en-
able prosocial engagement with others and attainment
of goals. SLTs understand the significance of commu-
nicative competence across the lifespan, for establishing
early attachment, acquiring a lexicon, transitioning to
literacy, achieving school attachment, forming proso-
cial relationships with peers, developing narrative com-
petence, encoding and decoding non-literal linguistic
forms (e.g. humour, sarcasm, metaphor), and mastering
conversational rules and pragmatic competence (Snow
and Powell 2004).
The SLT profession has not, however, positioned it-
self as being central to public mental health discourse,
and is therefore not invited to the ‘policy table’ when
important and pressing issues such as school bullying are
being debated. SLTs are an untapped spring of preven-
tion expertise but are not seen (by others or themselves)
as agents of prevention and are rarely taught population-
based primary prevention interventions in their train-
ing. This means they cannot occupy positions of influ-
ence with respect to policy-making at a population level
(Snow 2009).
Much is made in modern adolescent mental health
discourse of the notion of resilience—the ability to
‘bounce back’ after some kind of life adversity (e.g. Fuller
1998). This concept is, however, inherently limiting for
children who come from high-risk/disadvantaged back-
grounds, and who may have never experienced a sense of
security, emotional attunement on the part of key care-
givers, or self-efficacy. Yet we do know many factors that
foster resilience have a communication dimension (i.e.
the ability to verbalize one’s feelings, to succeed academ-
ically and to regulate one’s emotions) (Perry 2005) and
are central to the role played by the SLT. This supports
the argument that SLT as a profession needs to position
its expertise in relation to mental health and well-being
at a population level and across the lifespan (Law and
Elliott 2009, Snow 2009).
Speech and language therapy within a public
health context: a way forward
It is inevitable that SLT as a profession will need to
adopt a public health discourse in order to maintain
relevance in a changing policy context. Service-level
pressures, created by constricting budgets in the UK,
United States, Australia and elsewhere, mean it is not fea-
sible to retain traditional clinical models where caseloads
are commonly defined by severity, or where interven-
tions are likely to be diluted in an attempt to in-
crease the reach of services. Caseload management is
a challenge that policy-makers and SLT service man-
agers face on a daily basis (Kenny and Lincoln 2012).
492
Figure 1. A system for conceptualizing intervention and prevention within a public health context. Sources: after Mrazek and Haggerty (1994)
and Gascoigne (2006).
Restricting caseloads in this way is not sustainable and
may dilute the effectiveness of SLT services. Yet the
profession cannot expect to offer ‘everything to every-
one’ in a traditional, individualized therapeutic man-
ner. In addition to retaining one-to-one service delivery
models in situations that are well-supported by robust
efficacy and cost-effectiveness data, SLTs will need to
apply their expertise at policy levels in order to influ-
ence outcomes for populations. Population studies are
making it increasingly clear that prevention and inter-
vention for SLCN cannot be just about the disorders,
or even the extreme end of the spectrum of delays—it
must be about leveraging change with respect to social
determinants that operate at a population level. Our
understanding of disability has changed considerably
in recent years, initially in adults but latterly with re-
spect to children, both in relation to the Millennium
Development Goals (Olusanya et al. 2006) and to the
interpretation of the WHO International Classification
of Functioning, Disability and Health (ICF) framework
itself (WHO, Workgroup for Development of Version
of ICF for Children & Youth 2007, McLeod and Treats
2008).
Referring to a late 19th-century poem by Joseph Ma-
lins (1895), The Ambulance Down in the Valley, Hemen-
way (2009: 5) has argued that it is not helpful simply
to park more ambulances at the base of the cliff if the
poorly constructed/maintained guardrail at the top of
the cliff is allowing people to fall off easily. It could be
argued, then, that metaphorically SLT as a profession
has traditionally been ‘in the ambulance’, but it needs to
reposition its expertise to ensure that the top of the cliff
is made safer for all. If SLTs continue to locate them-
selves in these metaphorical ambulances, they will only
be able to negotiate for ‘more’ services for those who fall
off the cliff, rather than understanding who is at risk
of falling versus who will fall, and how falling can be
prevented.
James Law et al.
Examples of interventions
matched to level of need
‘The Lidcombe Program’
‘You Make the Difference’
‘Lets Read’
‘Communication Supporting
Classrooms’
What do we need to do?
We suggest that SLT as a profession needs to respond to
the following challenges:
r To develop models of communicative competence
that incorporate a robust understanding of the so-
cial determinants of health alongside our increas-
ingly sophisticated understanding of the underly-
ing biological and genetic bases of disability.
r To produce graduates who can generate innovative
solutions to population-based problems, within a
public health framework.
r To work with policy-makers to transform, where
necessary, existing services to permit these exciting
developments to take place.
r To conduct research within a public health frame-
work so as to fill much-needed evidence gaps and
demonstrate the broader policy relevance of com-
munication competence to well-being across the
lifespan.
Gascoigne (2006) has highlighted that the place of the
SLT in the health workforce might be considered within
what she described as the ‘pyramid of need’, whether that
be universal, targeted or specialist healthcare delivery.
Figure 1 suggests a model for SLT that combines the
ideas of Gascoigne with those of Mrazek and Haggerty
(1994) and which reflects the broad primary, secondary,
tertiary prevention model described above.
Universal approaches to intervention are compara-
ble with primary prevention. They cover the whole pop-
ulation and aim to prevent the development of future
problems. In situations involving disadvantage universal
approaches seek to change the balance between risk and
protective factors and thereby build resilience (Hawkins
et al. 2002).
Child speech, language and communication need in the context of public health 493

Build Healthy Public Policy

• What are the organizational constraints that impact on service capacity

to adopt a socio-ecological approach to communication competence?
• What changes need to be made to ensure fairness with respect to the development of
language and literacy skills?
• Are there policies in place that further disadvantage those who are already vulnerable
or disadvantaged with respect to communication competence?
• How can SLT expertise be brought to bear at a policy level?

Create Supportive Environments

• Are you working with the community or for the community?

• How will you provide community members with opportunities to have input to and
influence your service?
• How will practitioners ensure that some community members will not be marginalised
if decisions do not work as planned?

Strengthen Community Actions

• How will shared ownership of service goals be created?

• Can people’s life experiences with respect to communication competence be used as a
form of advocacy?
• Can the community strengthen its approach by using local and global research and
epidemiological data?

Develop Personal Skills

• Can the service be strengthened by mentoring members of the community?

• How will the wisdom of community members be drawn on and valued?
• How will consumers of a service be transformed into advocates of community-based
services?

Reorient Health Services

• In what ways do services address social, environmental and emotional determinants of

communication competence?
• What will be the process for ensuring that recommendations and actions result in
sustainable change (at individual and community levels)?
• Who, in position(s) of influence, do you need “on side” as a champion of
communicative competence for all?

Figure 2. Applying the Ottawa Charter to communication competence and speech and language therapy services.

Programmes such as ‘Lets Read’ (http://www.
letsread.com.au/pages/index.php) were designed to pro-
mote shared book reading and have been rolled out
by governments around the world. They are of-
fered to all parents of young children, regardless of
their position on the social gradient. Similarly, the
Communication Supporting Classrooms initiative has
been designed to improve the communication envi-
ronments of children in school (http://www.warwick.
ac.uk/go/bettercommunication) and is directed towards
all children and school staff.
Targeted intervention programmes correspond to sec-
ondary prevention and aim to decrease the prevalence
of a particular problem, e.g. early language delay. This
might include a language enrichment programme de-
livered to teenage mothers; in this instance the pro-
gramme is targeted to the mothers, with the desired
outcome being improved language environments for the
children and in the long-term, decreased prevalence of
language delay. Targeted interventions identify individ-
uals or groups of children whose risk of developing the
problem is higher than average. For example, late-talking
toddlers are at higher risk of developing later language
problems (Rescorla 2009). Specific interventions such
as the Hanen Centre’s You Make the Difference (Manol-
son et al. 1995) is an example of a targeted intervention
designed and has been shown to modify the late-talking
toddler’s language environment.
494
Specialist interventions or interventions correspond
to tertiary prevention and aim to reduce the impact
of the impairment and increase participation. They are
targeted at specific high-risk individuals. The Lidcombe
Program for preschool children who stutter is an exam-
ple of a specialist intervention (Jones et al. 2005). This
framework could be useful not only when considering
service delivery, but also it could be used to identify re-
search priorities and design appropriate studies. To give
an indication of how the field has tended to focus its
attention in terms of intervention, in a recent review of
the evidence supporting speech and language therapy
interventions we identified 60 interventions that were
able to report some level of empirical support (Law et al.
2012). Of these, however, only five could be described
as focusing on primary prevention or universal services,
the remainder being targeted or specialist.
The Ottawa Charter for Health Promotion (WHO
1986) offers a framework for both educators and clin-
icians as a basis for reconceptualizing the skill-base of
SLT as a profession, and considering ways in which a
shift towards a public-health orientation might be com-
menced. This charter conceptualizes health promotion
action around five key approaches: (1) Build Healthy
Public Policy, (2) Create Supportive Environments, (3)
Strengthen Community Actions, (4) Develop Personal
Skills, and (5) Re-orient Health Services. Figure 2 sum-
marizes these approaches and poses initial questions for
clinicians and educators to assist with a repositioning
of the profession, towards identifying and targeting so-
cial determinants of communicative competence at a
population level.
Finally, the question turns to how SLTs are likely to
respond to the proposed shift in professional emphasis.
While this issue has not been addressed with specific re-
gard to public health, a comparable discussion has been
initiated in terms of health promotion, which can be
construed as an element of primary prevention or uni-
versal service provision. Indeed, it has been argued that
SLTs at an individual and in some cases service level
have already moved away from might be called tradi-
tional one-to-one or direct models of service delivery
towards a model of empowering identified groups (Fer-
guson and Spence 2012). The shift to a public health
approach represents the next logical step.
In conclusion, we argue that the speech and language
therapy profession has little choice but to reconsider its
orientation as a primarily clinical service and to start to
embrace public health principles. This will, of course,
need to continue to include targeted and specialist in-
terventions, but only as elements of a larger picture.
Adopting a public health approach should also facili-
tate the application of health economic modelling, to
enable reliable estimates of the costs (financial and so-
cial) of SLCN across the lifespan. The good news is
James Law et al.
that SLTs are resourceful, adaptable individuals and well
equipped to debate these matters, and in doing so to
respond to the challenges ahead. When responding to
criticism during a discussion of monetary policy, John
Maynard Keynes was said to have replied, ‘When the
facts change I change my mind. What do you do sir?’
(quoted in Malabre 1994). The facts for SLT as a profes-
sion are changing and a review of itsxenlrg orientation
and positioning is overdue.
Acknowledgements
Suzanne Moffat, public health researcher and speech and language
therapist at the Institute of Health and Society in Newcastle Uni-
versity, UK, and Dr Bernadette Ward at the School of Rural Health,
Monash University, Melbourne, Australia, are thanked for comment-
ing on earlier versions of this manuscript. Louise Waldrop, personal
assistant to Professor Reilly at the Murdoch Children’s Research In-
stitute, is also thanked for help with the manuscript. Declaration
of interest: The authors report no conflicts of interest. The authors
alone are responsible for the content and writing of the paper.
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