Scope of Practice in Speech-Language Pathology

Scope of Practice in Speech-Language Pathology

Reference: American Speech-Language-Hearing Association. (2016). Scope of Practice in Speech-Language Pathology.

About This Document

  • Official policy of the American Speech-Language-Hearing Association (ASHA).
  • Defines the breadth of practice within speech-language pathology.
  • Developed by the ASHA Ad Hoc Committee on the Scope of Practice in Speech-Language Pathology.
  • Approved by the ASHA Board of Directors on February 4, 2016 (BOD 01-2016), with a revision on May 9, 2016 (Motion 07-2016) regarding prevention of hearing.

Table of Contents:

  • Introduction
  • Statement of Purpose
  • Definitions of Speech-Language Pathologist and Speech-Language Pathology
  • Framework for Speech-Language Pathology Practice
  • Domains of Speech-Language Pathology Service Delivery
  • Speech-Language Pathology Service Delivery Areas
  • Domains of Professional Practice
  • References
  • Resources

Introduction

  • The Scope of Practice includes:
    • Statement of purpose
    • Definitions of speech-language pathologist and speech-language pathology
    • Framework for practice
    • Description of service delivery domains
    • Delineation of service delivery areas
    • Domains of professional practice
    • References and resources
  • Speech-Language Pathologist (SLP): A professional who practices in communication and swallowing across the lifespan.
  • Communication: Includes speech production, fluency, language, cognition, voice, resonance, and hearing.
  • Swallowing: Includes all aspects of swallowing, including related feeding behaviors.
  • The document is a guide for SLPs in clinical and educational settings to promote best practice.
  • Individuals: Refers to students, clients, and patients served by the SLP.
  • The document reflects recent advances in knowledge and research.

Key Changes:

  • Delineation of practice areas into eight domains of speech-language pathology service delivery:
    • Collaboration
    • Counseling
    • Prevention and Wellness
    • Screening
    • Assessment
    • Treatment
    • Modalities, Technology, and Instrumentation
    • Population and Systems
  • Five domains of professional practice:
    • Advocacy and Outreach
    • Supervision
    • Education
    • Research
    • Administration/Leadership
  • Service delivery areas include all aspects of communication, swallowing, and related areas that impact them (speech production, fluency, language, cognition, voice, resonance, feeding, swallowing, and hearing).
  • SLPs play critical roles in health literacy, autism spectrum disorder, and using the International Classification of Functioning, Disability and Health (ICF).
  • Clinicians should stay current with advances in practice by:
    • Reviewing research literature
    • Consulting the ASHA website's Practice Management section, including the Practice Portal
    • Participating in continuing education

Statement of Purpose

The purpose of the Scope of Practice in Speech-Language Pathology is to:

  1. Delineate areas of professional practice.
  2. Inform others (health care providers, educators, consumers, payers, regulators, general public) about roles and responsibilities.
  3. Support SLPs in providing high-quality, evidence-based services.
  4. Support SLPs in research conduct and dissemination.
  5. Guide educational preparation and professional development.
  • The scope outlines the breadth of services.
  • Levels of education, experience, skill, and proficiency vary among providers.
  • SLPs should practice only in areas of competence, based on education, training, and experience, as per the ASHA Code of Ethics.
  • The document describes evolving practice areas, including interdisciplinary work, collaborative service delivery, and telehealth/telepractice.
  • SLPs collaborate with other professionals to make sound decisions for individuals with communication and swallowing disorders.
  • Interprofessional collaborative practice: “members or students of two or more professions associated with health or social care, engaged in learning with, from and about each other” (Craddock, O’Halloran, Borthwick, & McPherson, 2006, p. 237).
  • Interprofessional education provides shared skills and knowledge, better understanding, shared values, and respect for other healthcare professionals' roles (Bridges et al., 2011).
  • The scope of practice does not supersede state licensure laws but may serve as a model for their development.
  • ASHA professional resources outline practice areas and address public protection (e.g., A guide to disability rights law and the Practice Portal).
  • The highest standards of integrity and ethical conduct are paramount.

Definitions of Speech-Language Pathologist and Speech-Language Pathology

  • SLPs hold the ASHA Certificate of Clinical Competence in Speech-Language Pathology (CCC-SLP), requiring a master’s, doctoral, or postbaccalaureate degree.
  • ASHA-certified SLPs complete supervised postgraduate professional experience and pass a national examination.
  • Continued professional development is required for CCC-SLP maintenance.
  • SLPs hold other required credentials (e.g., state licensure, teaching certification, specialty certification).
  • Practitioners evaluate their experiences with education, practice, mentorship, supervision, and professional development to define competence.
  • SLPs should practice within their professional competence.
  • SLPs are autonomous professionals and primary care providers of speech-language pathology services; services are not prescribed or supervised by another professional.
  • Professional judgment is used to determine if additional requirements are indicated.
  • Collaboration with other professionals benefits individuals with communication and/or swallowing disorders.
  • Speech-language pathology practice includes both service delivery and professional practice domains.

Framework for Speech-Language Pathology Practice

  • The overall objective is to optimize individuals’ abilities to communicate and swallow, improving quality of life.
  • SLPs provide culturally and linguistically appropriate services, considering diversity in scientific investigations.
  • Decisions are based on best available evidence.
  • Evidence-based practice: Integrating current, high-quality research evidence with practitioner expertise and client values and preferences (ASHA, 2005).
  • A high-quality research base is essential for evidence-based practice.
  • Increased national and international interchange strengthens research collaboration and improves services.
  • ASHA provides a resource for evidence-based research via the Practice Portal.
  • The scope of practice includes five domains of professional practice and eight domains of service delivery:
    • Professional practice domains:
      • Advocacy and outreach
      • Supervision
      • Education
      • Administration/leadership
      • Research
    • Service delivery domains:
      • Collaboration
      • Counseling
      • Prevention and Wellness
      • Screening
      • Assessment
      • Treatment
      • Modalities, Technology, and Instrumentation
      • Population and Systems
  • SLPs provide services to individuals with a wide range of speech, language, and swallowing differences and disorders that vary in function.
  • Diagnostic categories align with the WHO’s (2014) ICF, the American Psychiatric Association’s (2013) Diagnostic and Statistical Manual of Mental Disorders, IDEA of 2004, and those defined by ASHA's Council on Academic Accreditation and Council for Clinical Certification.
  • Domains of speech-language pathology service delivery complement the ICF, which provides a standard language for describing functioning and health.
  • The ICF framework describes the role of the SLP in prevention, assessment, and habilitation/rehabilitation of communication and swallowing disorders.

ICF Framework Components:

  • Health Conditions
    • Body Functions and Structures: Anatomy and physiology of the human body.
      • Examples: craniofacial anomaly, vocal fold paralysis, cerebral palsy, stuttering, and language impairment.
    • Activity and Participation: Execution of a task or action and involvement in a life situation.
      • Examples: difficulties with swallowing safely, participating in class, understanding a medical prescription, and accessing the general education curriculum.
  • Contextual Factors
    • Environmental Factors: Physical, social, and attitudinal environments.
      • Examples: the role of the communication partner in AAC, the influence of classroom acoustics, and the impact of dining environments on nutrition and hydration.
    • Personal Factors: Internal influences on functioning and disability.
      • Examples: age, gender, ethnicity, educational level, social background, and profession, if influencing reaction to communication or swallowing.
  • The framework encompasses health conditions and contextual factors across individuals and populations.
  • Health conditions exist on a continuum from intact to completely compromised functioning.
  • Contextual factors interact with each other and with health conditions, serving as facilitators or barriers to functioning.
  • SLPs influence contextual factors through education and advocacy.

Domains of Speech-Language Pathology Service Delivery

  • Eight domains:
    • Collaboration
    • Counseling
    • Prevention and Wellness
    • Screening
    • Assessment
    • Treatment
    • Modalities, Technology, and Instrumentation
    • Population and Systems

Collaboration

  • SLPs share responsibility with other professionals for creating a collaborative culture.
  • Collaboration requires joint communication and shared decision making among team members, including the individual and family.
  • Professionals are ethically and legally obligated to ensure they have the necessary knowledge and skills.
  • Collaboration occurs across all speech-language pathology practice domains.
  • Increased national and international interchange of professional knowledge strengthens research collaboration and improves services.
  • SLPs:
    • Educate stakeholders regarding interprofessional education (IPE) and interprofessional practice (IPP) principles and competencies (ASHA, 2014).
    • Partner with other professions/organizations to enhance the value of speech-language pathology services.
    • Share responsibilities to achieve functional outcomes.
    • Consult with other professionals to meet the needs of individuals with communication and swallowing disorders.
    • Serve as case managers, service delivery coordinators, and members of collaborative and patient care conference teams.
    • Serve on early intervention and school pre-referral and intervention teams to assist with IFSPs and IEPs.

Counseling

  • SLPs counsel by providing education, guidance, and support.
  • Counseling involves acceptance, adaptation, and decision making about communication, feeding and swallowing, and related disorders.
  • The role includes interactions related to emotional reactions, thoughts, feelings, and behaviors resulting from living with the disorder.
  • SLPs engage in the following:
    • Empower the individual and family to make informed decisions.
    • Educate the individual, family, and community members about disorders.
    • Provide support and/or peer-to-peer groups.
    • Provide individuals and families with self-advocacy skills.
    • Discuss, evaluate, and address negative emotions and thoughts.
    • Refer individuals to other professionals when counseling needs fall outside of communication, feeding, and swallowing.

Prevention and Wellness

  • SLPs are involved in reducing the incidence of new disorders or diseases, identifying disorders early, and decreasing the severity or impact of existing ones.
  • Involvement is directed toward individuals at risk for limited participation in communication, hearing, feeding and swallowing, and related abilities.
  • Activities enhance or improve general well-being and quality of life.
  • Education focuses on identifying and increasing awareness of risk behaviors.
  • SLPs promote programs to increase public awareness and positively change behaviors or attitudes.
  • Effective programs are community-based and reduce the incidence of communication and swallowing disorders as a public health and education concern.
  • Examples:
    • Language impairment: Educate about clinical markers and impact on reading and writing skills.
    • Language-based literacy disorders: Educate about the SLP’s role in addressing semantic, syntactic, morphological, and phonological aspects.
    • Feeding: Educate parents of infants at risk about techniques to minimize long-term challenges.
    • Stroke prevention: Educate about risk factors.
    • Serve on teams: Participate on MTSS/RTI teams.
    • Fluency: Educate parents about risk factors associated with early stuttering.
    • Early childhood: Encourage participation in early screening and collaboration to recognize warning signs.
    • Prenatal care: Educate to decrease the incidence of disorders due to problems during pregnancy.
    • Genetic counseling: Refer individuals to appropriate professionals.
    • Environmental change: Modify environments to decrease risk.
    • Vocal hygiene: Target prevention of voice disorders.
    • Hearing: Educate about risk factors associated with noise-induced hearing loss.
    • Concussion/traumatic brain injury awareness: Educate parents of children in contact sports.
    • Accent/dialect modification: Address sound pronunciation, stress, rhythm, and intonation.
    • Transgender (TG) and transsexual (TS) voice and communication: Educate and treat individuals about verbal, nonverbal, and voice characteristics.
    • Business communication: Educate about the importance of effective communication.
    • Swallowing: Educate individuals at risk for aspiration about oral hygiene techniques.

Screening

  • SLPs are experts at screening for possible communication, hearing, and/or feeding and swallowing disorders.
  • SLPs design and implement effective screening programs and make appropriate referrals.
  • Screenings facilitate referral for appropriate follow-up in a timely and cost-effective manner.
  • SLPs:
    • Select and use appropriate screening instrumentation.
    • Develop screening procedures and tools based on existing evidence.
    • Coordinate and conduct screening programs.
    • Participate in public school MTSS/RTI team meetings.
    • Review and analyze records.
    • Review, analyze, and make appropriate referrals based on results.
    • Consult with others about screening results.
    • Utilize data to inform decisions about the health of populations.

Assessment

  • SLPs have expertise in the differential diagnosis of disorders of communication and swallowing.
  • Disorders can occur developmentally, as part of a medical condition, or in isolation.
  • SLPs diagnose communication and swallowing disorders but do not differentially diagnose medical conditions.
  • The assessment process utilizes the ICF framework.
  • The process includes culturally and linguistically appropriate behavioral observation, standardized and/or criterion-referenced tools, instrumentation, review of records, case history, and interview of the individual and/or family.
  • The assessment process can be carried out in collaboration with other professionals.
  • SLPs:
    • Administer standardized and/or criterion-referenced tools.
    • Review medical records.
    • Interview individuals and/or family.
    • Utilize culturally and linguistically appropriate assessment protocols.
    • Engage in behavioral observation.
    • Diagnose communication and swallowing disorders.
    • Use endoscopy, videofluoroscopy, and other instrumentation.
    • Document assessment and trial results for selecting AAC interventions and technology, including speech-generating devices (SGDs).
    • Participate in meetings adhering to federal and state laws and regulations (e.g., IDEIA [2004] and Section 504 of the Rehabilitation Act of 1973).
    • Document assessment results, including discharge planning.
    • Formulate impressions to develop a plan of treatment and recommendations.
    • Discuss eligibility and criteria for dismissal from early intervention and school-based services.

Treatment

  • Services are designed to optimize individuals’ ability to communicate and swallow, thereby improving quality of life.
  • SLPs develop and implement treatment to address the presenting symptoms or concerns.
  • Treatment establishes a new skill or ability or remediates or restores an impaired skill or ability.
  • The ultimate goal is to improve functional outcomes.
  • SLPs:
    • Design, implement, and document delivery of service in accordance with best available practice.
    • Provide culturally and linguistically appropriate services.
    • Integrate the highest quality available research evidence with practitioner expertise and individual preferences and values.
    • Utilize treatment data to guide decisions and determine the effectiveness of services.
    • Integrate academic materials and goals into treatment.
    • Deliver the appropriate frequency and intensity of treatment utilizing best available practice.
    • Engage in treatment activities that are within the scope of the professional’s competence.
    • Utilize AAC performance data to guide clinical decisions and determine the effectiveness of treatment.
    • Collaborate with other professionals in the delivery of services.

Modalities, Technology, and Instrumentation

  • SLPs use advanced instrumentation and technologies in the evaluation, management, and care of individuals with communication, feeding and swallowing, and related disorders.
  • SLPs are involved in the research and development of emerging technologies and apply their knowledge to enhance the quality of services.
  • Examples:
    • AAC technologies for individuals with impaired ability to communicate verbally.
    • Endoscopy, videofluoroscopy, fiber-optic evaluation of swallowing to assess voice, resonance, and swallowing.
    • Telehealth/telepractice to provide access to services or specialists.
    • Ultrasound and other biofeedback systems for speech sound production, voice, or swallowing disorders.
    • Other modalities (e.g., American Sign Language), where appropriate.

Population and Systems

  • SLPs have a role in:
    • Managing populations to improve overall health and education.
    • Improving the experience of the individuals served.
    • Reducing the cost of care.
  • SLPs also improve the efficiency and effectiveness of service delivery, serving in roles designed to meet the demands of a changing work environment.
  • SLPs:
    • Use plain language to facilitate clear communication.
    • Collaborate with other professionals about improving communication with individuals who have communication challenges.
    • Improve the experience of care by analyzing and improving communication environments.
    • Reduce the cost of care by designing and implementing case management strategies.
    • Serve in roles designed to meet the demands and expectations of a changing work environment.
    • Contribute to the management of specific populations by enhancing communication between professionals and individuals served.
    • Coach families and early intervention providers about strategies and supports for facilitating communication skills of infants and toddlers.
    • Support and collaborate with classroom teachers to implement strategies for supporting student access to the curriculum.

Speech-Language Pathology Service Delivery Areas

  • The list is not comprehensive; current areas evolve, and new areas emerge.
  1. Fluency
    • Stuttering
    • Cluttering
  2. Speech Production
    • Motor planning and execution
    • Articulation
    • Phonological
  3. Language—Spoken and written language (listening, processing, speaking, reading, writing, pragmatics)
    • Phonology
    • Morphology
    • Syntax
    • Semantics
    • Pragmatics (language use and social aspects of communication)
    • Prelinguistic communication (e.g., joint attention, intentionality, communicative signaling)
    • Paralinguistic communication (e.g., gestures, signs, body language)
    • Literacy (reading, writing, spelling)
  4. Cognition
    • Attention
    • Memory
    • Problem solving
    • Executive functioning
  5. Voice
    • Phonation quality
    • Pitch
    • Loudness
    • Alaryngeal voice
  6. Resonance
    • Hypernasality
    • Hyponasality
    • Cul-de-sac resonance
    • Forward focus
  7. Feeding and Swallowing
    • Oral phase
    • Pharyngeal phase
    • Esophageal phase
    • Atypical eating (e.g., food selectivity/refusal, negative physiologic response)
  8. Auditory Habilitation/Rehabilitation
    • Speech, language, communication, and listening skills impacted by hearing loss, deafness
    • Auditory processing

Potential Etiologies:

  • Neonatal problems (e.g., prematurity, low birth weight, substance exposure)
  • Developmental disabilities (e.g., specific language impairment, autism spectrum disorder, dyslexia, learning disabilities, attention-deficit disorder, intellectual disabilities, unspecified neurodevelopmental disorders)
  • Disorders of aerodigestive tract function (e.g., irritable larynx, chronic cough, abnormal respiratory patterns or airway protection, paradoxical vocal fold motion, tracheostomy)
  • Oral anomalies (e.g., cleft lip/palate, dental malocclusion, macroglossia, oral motor dysfunction)
  • Respiratory patterns and compromise (e.g., bronchopulmonary dysplasia, chronic obstructive pulmonary disease)
  • Pharyngeal anomalies (e.g., upper airway obstruction, velopharyngeal insufficiency/incompetence)
  • Laryngeal anomalies (e.g., vocal fold pathology, tracheal stenosis)
  • Neurological disease/dysfunction (e.g., traumatic brain injury, cerebral palsy, cerebrovascular accident, dementia, Parkinson’s disease, and amyotrophic lateral sclerosis)
  • Psychiatric disorder (e.g., psychosis, schizophrenia)
  • Genetic disorders (e.g., Down syndrome, fragile X syndrome, Rett syndrome, velocardiofacial syndrome)
  • Orofacial myofunctional disorders (e.g., habitual open-mouth posture/nasal breathing, orofacial habits, tethered oral tissues, chewing and chewing muscles, lips and tongue resting position).

Elective Services:

  • Transgender communication (e.g., voice, verbal and nonverbal communication)
  • Preventive vocal hygiene
  • Business communication
  • Accent/dialect modification
  • Professional voice use

Domains of Professional Practice

  • Skills and knowledge beyond clinical practice.

Domains:

  • Advocacy and Outreach
  • Supervision
  • Education
  • Research
  • Administration and Leadership

Advocacy and Outreach

  • SLPs advocate for the discipline and individuals through community awareness, prevention, health literacy, education, political action, and training programs.
  • Advocacy promotes and facilitates access to communication and reduces societal, cultural, and linguistic barriers.
  • SLPs:
    • Advise regulatory and legislative agencies about the continuum of care.
    • Engage decision makers for improved policies affecting access to services and funding.
    • Advocate for funding for services, education, and research.
    • Participate in associations and organizations.
    • Promote and market professional services.
    • Help to recruit and retain diverse SLPs.
    • Collaborate on advocacy objectives.
    • Serve as expert witnesses, when appropriate.
    • Educate consumers about communication disorders and services.
    • Advocate for fair and equitable services.
    • Inform state education agencies and local school districts about the roles and responsibilities of school-based SLPs.

Supervision

  • A distinct area of practice; is the responsibility of SLPs; and crosses clinical, administrative, and technical spheres.
  • SLPs supervise Clinical Fellows, graduate externs, trainees, speech-language pathology assistants, and other personnel.
  • Supervision is integral in service delivery and advances the discipline.
  • Involves education, mentorship, encouragement, counseling, and support.
  • SLPs:
    • Possess service delivery and professional practice skills to guide the supervisee.
    • Apply the art and science of supervision to all stakeholders.
    • Seek advanced knowledge in effective supervision.
    • Establish collegial supervisory relationships.
    • Support supervisees in handling emotional reactions.
    • Establish a relationship that promotes growth and independence while providing support and guidance.

Education

  • SLPs serve as educators in academic institutions and through continuing education.
  • Includes education to individuals, families, caregivers, decision makers, and policy makers.
  • SLPs:
    • Serve as faculty at institutions of higher education.
    • Mentor students completing academic programs.
    • Provide academic training to students in related disciplines and to those training to become speech-language pathology assistants.
    • Provide continuing professional education to SLPs and other professionals.

Research

  • SLPs conduct and participate in basic and applied/translational research related to cognition, verbal and nonverbal communication, pragmatics, literacy, and feeding and swallowing.
  • Research may be facility-specific or coordinated across multiple settings.
  • SLPs ensure compliance with Institutional Review Boards and international laws pertaining to research.
  • SLPs collaborate with other researchers and may pursue research funding through grants.

Administration and Leadership

  • SLPs administer programs in education, higher education, schools, health care, private practice, and other settings.
  • They make administrative decisions related to fiscal and personnel management, leadership, program design, program growth and innovation, professional development, compliance with laws and regulations, and cooperation with outside agencies.
  • Administrative roles are not limited to speech-language pathology.
  • SLPs promote effective workloads in school settings, provide appropriate services under IDEIA (2004), and engage in program design and development.

References

  • American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Washington, DC: Author.
  • American Speech-Language-Hearing Association. (2005). Evidence-based practice in communication disorders [Position statement]. Available from www.asha.org/policy/.
  • American Speech-Language-Hearing Association. (2014). Interprofessional education/interprofessional practice (IPE/IPP). Available from https://www.asha.org/Practice/Interprofessional-Education-Practice/.
  • Bridges, D. R., Davidson, R. A., Odegard, P. S., Maki, I. V., & Tomkowiak, J. (2011). Interprofessional collaboration: Three best practice models of interprofessional education. Medical Education Online, 16. doi:10.3402/meo.v16i0.6035.
  • Craddock, D., O’Halloran, C., Borthwick, A., & McPherson, K. (2006). Interprofessional education in health and social care: Fashion or informed practice? Learning in Health and Social Care, 5, 220–242.
  • Individuals With Disabilities Education Act of 2004, 20 U.S.C. § 1400 et seq. (2004).
  • Lipinski, C. A., Lombardo, F., Dominy, B. W., & Feeney, P. J. (1997, March 1). Experimental and computational approaches to estimate solubility and permeability in drug discovery and development settings. Advanced Drug Delivery Reviews, 46(1–3), 3–26.
  • Rehabilitation Act of 1973, 29 U.S.C. § 701 et seq.
  • U.S. Department of Education. (2004). Building the legacy: IDEA 2004. Retrieved from http://idea.ed.gov/.
  • World Health Organization. (2014). International Classification of Functioning, Disability and Health. Geneva, Switzerland: Author.

Resources

  • American Speech-Language-Hearing Association. (n.d.). Introduction to evidence-based practice. Retrieved from www.asha.org/Research/EBP/.
  • American Speech-Language-Hearing Association. (n.d.). Practice Portal. Available from www.asha.org/practice-portal/.
  • American Speech-Language-Hearing Association. (1991). A model for collaborative service delivery for students with language-learning disorders in the public schools [Paper]. Available from www.asha.org/policy/.
  • American Speech-Language-Hearing Association. (2003). Evaluating and treating communication and cognitive disorders: Approaches to referral and collaboration for speech-language pathology and clinical neuropsychology [Technical report]. Available from www.asha.org/policy/.
  • Paul, D. (2013, August). A quick guide to DSM-V. The ASHA Leader, 18, 52–54.
  • U.S. Department of Justice. (2009). A guide to disability rights laws. Retrieved from www.ada.gov/cguide.htm.