Speech-Language Pathologist and Parent Perspectives on Speech-Language Pathology Services for Children With Autism Spectrum Disorders

Abstract

Many speech-language pathologists (SLPs) are underprepared to serve children with autism spectrum disorders (ASDs), despite a growing need and increased expectation for ASD expertise. To understand this practice gap, 60 SLPs and 26 parents of children with ASDs were surveyed regarding SLP knowledge and competency. Of concern was that only about 50% of SLPs correctly identified ASD defining criteria. Respondents rated eight SLP practices as Important to Very Important, but SLPs reported being only Somewhat Competent to Competent. The parents’ rating of SLP competency was significantly lower than parental ratings of importance for one educational practice, use of nonstandardized assessment and observational methods. Also, parents rated the development of the Individualized Education Program significantly higher in importance than SLPs rated it. Findings varied for ASD specialty subgroups. Results support socially valid improvements in preparation for SLPs on the frontlines of assessment, treatment, and development of health and educational systems for children with ASDs.

Keywords

autism spectrum disorders speech-language pathology language personnel preparation parent

Introduction

The Centers for Disease Control (CDC) indicated prevalence for autism spectrum disorders (ASDs) among 8-year-olds at an astonishing rate of 1 in 59 U.S. children diagnosed in 2014 (Baio et al., 2018). This was an increase from about 7 in 1,000 sampled children at the start of the 21st century to almost 15 in 1,000 children for 2014. Although reporting agencies and methods differ, all indicators pointed to a doubling in prevalence, and the CDC concluded data likely represent a true increase. Parents of children with ASDs and speech-language pathologists (SLPs) are two groups affected by substantial increases in the past two decades. After all, significant increases in ASDs result in overwhelming numbers of children needing assessment, early intervention, preschool programs, and general and special education services.

SLPs are called upon as key early providers. That is, parents are referred to SLPs by primary care physicians when their children have not started talking. Although late language emergence is a characteristic of developmental language disorders associated with other developmental disabilities or nonspecific etiologies, it can be an early symptom of language disorder associated with ASDs. More specifically, social communication deficits are core ASD features, and increasingly social communication deficits in 1-year-olds can be reliably identified and serve as stable predictors (Pierce et al., 2019; Wetherby et al., 2007). For these reasons, SLPs serving pediatric populations have a substantial responsibility to differentially identify characteristics of ASDs for children presenting with late language emergence. After identification, SLPs intervene across childhood to facilitate language development and social interaction skills—starting with prelinguistic behaviors such as joint attention and gesture, evolving to intentional verbal communication to request and comment, and building to multiword utterances and literacy skills. Early identification and provision of speech-language treatment addressing language and social communication are critical for children with ASDs and predictive of outcomes. Early identification of ASDs is associated with school success for children as young as age 5 years (Volkers, 2016), and relatively better language ability is a significant positive prognostic factor for children with ASDs (Koegel, 2000). Consistent with this, 93% of surveyed parents of children with ASDs reported currently or previously utilizing speech-language therapy (Green et al., 2006). SLPs and parents can form important partnerships early and over time to support and optimize outcomes for children with ASDs.

The American Speech-Language-Hearing Association (ASHA, 2016, n.d.-b), the professional and certifying organization for SLPs, publishes guidelines defining the scope of practice, roles and responsibilities, necessary knowledge and skills for practicing SLPs serving individuals with ASD, and up-to-date references for evidence-based practices. The challenge, however, is that speech-language pathology is a broad field that covers diverse populations and services. A master’s degree, the level of preparation for certification, provides general preparation for many communicative disorders and practice settings but does not support specialization. Given this preparation model, SLPs needed to serve the increasing numbers of persons with ASDs may not be suitably prepared.

Several studies have investigated the preparation and expertise of SLPs serving individuals with ASDs (Cascella & Colella, 2004; Plumb & Plexico, 2013; Schwartz & Drager, 2008). Cascella and Colella (2004) surveyed school-based SLPs regarding ASD knowledge for aspects like atypical play behaviors and social interaction as well as understanding low-tech augmentative and alternative communication (AAC) applications and assessing verbal development. Sixty-nine percent of SLPs reported that undergraduate and graduate programs provided very little training in ASDs, but 82% of participants reported participating in continuing education on ASDs. SLPs rated themselves as knowledgeable to very knowledgeable for behavioral descriptions of ASDs but somewhat to minimally knowledgeable for dynamic assessment and assessing parent–child conversations. Schwartz and Drager (2008) surveyed SLPs’ knowledge of ASD characteristics (e.g., true/false, “children must exhibit impaired social interaction to receive a diagnosis of autism”) and self-rated ASD competency (e.g., Likert-type rating, “I feel competent in my ability to determine appropriate intervention goals for children with autism at all stages of therapy.” p. 72) and found that SLPs were not knowledgeable of diagnostic criteria for ASDs but were knowledgeable about general ASD characteristics. SLPs were relatively unsure of their skills for serving children with ASDs. Of the 67 SLPs across 33 states, only 2 had an entire graduate course devoted to ASDs, but 77% said they participated in one or more graduate classes that addressed ASDs. When asked about the duration of ASD content, 81% indicated it was about 1 week. Plumb and Plexico (2013) documented increases in training provided to SLPs between 2006 and 2012. The more recent graduates were two times more likely to have had an entire course or to have had two or three courses that addressed the topic of ASDs. Despite the increase in dedicated course work, those who graduated before 2006 expressed more confidence in counseling parents about early signs of ASDs and providing social skills intervention. Work-related experience and continuing education were likely factors supporting greater confidence for the older group of SLPs compared with the more recent graduates.

SLPs are not the only group challenged to serve individuals with ASDs effectively. Investigators have sought to delineate the skills and confidence for educators (Brock et al., 2014) and other health care providers (Heidgerken et al., 2005). Brock et al. (2014) concluded that evidence-based practices for children with ASDs were not being applied in Tennessee schools based on responses from 456 teachers, special educators, and administrators. Teachers rated their confidence for implementing specific evidence-based strategies (e.g., time delay, peer-mediated interventions) between 2.12 and 3.54 on a Likert-type scale (1 = not at all confident to 5 = very confident). Surprisingly, teachers were not interested in ASD continuing education opportunities.

Iadarola et al. (2015) reported a primary theme of tension between school-based personnel and parents of children with ASDs. Focus group findings revealed that school personnel bemoaned a lack of parental follow-through and parents did not trust school personnel to meet children’s needs. Parents expressed concerns regarding teachers’ limited knowledge of behavior management, and both parents and teachers stated the importance of social skills but indicated a need for additional training. Bitterman et al. (2008) found that parents of preschoolers with ASDs were more likely to express dissatisfaction than parents of children with other developmental delays. Parents of preschoolers with ASDs said their children received too few treatment hours weekly and too few opportunities with peers despite receiving significantly more hours of speech-language therapy and other services in and out of school (e.g., occupational therapy, behavior management, and one-to-one aides) compared with children with other disabilities. Spann et al. (2003), like Iadarola et al. (2015), reported that social, language, and communication were parent priorities. Almost half (44%) expressed dissatisfaction with school services and this increased to 83% for older children (15–18 years).

Given the increased need for high-quality services for persons with ASDs, specialization and certificate programs have emerged and are increasing (Barnhill et al., 2013). Specialization in ASDs can mean a variety of things. Since 2001, third-party certification is available from the International Board of Credentialing and Continuing Education Standards (IBCCES, n.d.). Board-certified behavior analysts, teachers, SLPs, and others can become Certified Autism Specialists ^TM by meeting IBCCES educational, professional experience, and continuing education standards. Barnhill et al. (2013) surveyed higher education institutions about the ASD credentialing practices of special education programs. They found that, of institutions offering ASD coursework (N = 90), 22% provided no specific certification, 29% offered a completion certificate, 18% provided state licensure or an endorsement, and 20% provided a degree concentration. ASHA recently approved the formation of a Specialty Certification Board in ASDs (ASHA, n.d.-a). The SLP specialty certification program in ASDs is expected to encompass a set of minimum standards: 450 clinical hours with persons with ASDs, 60 hours of continuing education in ASDs at an intermediate or advanced level, and a passing score on standardized assessment. Other fields with ASDs as part of their scope of practice, such as psychiatry and pediatrics, report a relatively low rate of ASD specialists, such that recruiting trainees and staffing programs with trainers is challenging (Hsu, 2018; Marrus et al., 2014).

In summary, the prevalence of ASDs has increased steadily in ways that tax existing providers and services, and there is a corresponding push to develop and identify ASD expertise. Previous survey studies revealed limitations in the ASD training of SLPs and other professionals, and investigations of the perceptions of parents of children with ASDs revealed dissatisfaction with school-based personnel’s knowledge and training. Our first aim was to compare perspectives of SLPs and parents, two primary stakeholder groups. Research questions to address this aim were as follows:

Research Question 1: Are there significant differences between SLPs and parents regarding accurate knowledge of diagnostic criteria and associated characteristics of ASDs?

Research Question 2: Are there significant differences between and within SLP and parent groups for ratings of the importance of and SLP competency for targeted ASD assessment and intervention tools?

Research Question 3: Are there significant differences between SLP and parent groups for ratings of the importance of select educational practices associated with ASDs?

Our second aim was to investigate parents’ and SLPs’ perceptions regarding ASD specialists. We asked the following:

Research Question 4: Are there significant differences in parent and SLP perceptions regarding which professions they perceived as being ASD specialists?

Research Question 5: What are SLPs’ perceptions regarding the need for ASD specialty?

Finally, we conducted an unplanned, post hoc analysis to address the following:

Research Question 6: Are there significant differences for key survey items for SLPs who self-reported as ASD specialists compared with nonspecialists.

Understanding gaps in knowledge and perception for SLPs compared with the parents of children with ASDs can support improved training of SLPs, a group of critical service providers.

Method

Participants

Eighty-six individuals participated: 60 SLPs and 26 parents of children with ASDs. All but one SLP and 22 of 25 parents were female. Most SLPs were 26 to 35 years of age (38%). Participants were from the lower Alabama, Gulf Coast region: SLPs practiced in Alabama (61%), Florida (28%), Mississippi (9%), and Georgia (2%), and parents resided in Alabama (54%), Mississippi (34%), Florida (4%), and Texas (4%). Parents were primarily college educated, and 91% of SLPs held master’s degrees. SLP experience levels were split with 30% of SLPs having 1 to 5 years of experience and 32% reporting 16+ years. Only two SLPs reported less than 1 year of experience. A majority of SLPs (74%) worked in schools. When asked about their education, SLPs reported having no courses that solely addressed ASDs in undergraduate (87%) or graduate (81%) programs, but 72% reported having one or two graduate courses that addressed ASDs for up to 2 weeks. Seventy-five percent of SLPs said they sought continuing education in ASDs.

Survey Creation

Separate surveys for SLPs and parents were created but sections overlapped to enable group comparisons. Surveys were created using Survey Monkey, an online provider with a secure server, and Secure Sockets Layer (SSL) encryption. Each survey had a cover page with the title, contact information, and institutional review board (IRB) details. If consenting, participants saw a brief overview of the survey purpose and some relevant statistics regarding ASDs. Definitions of ASDs were not provided because this information was surveyed.

The first section (see Figure 1), “Characteristics of Autism” Questions 2 through 9 in both the SLP and parent surveys, assessed knowledge of the diagnostic criteria and some associated characteristics for ASDs. These eight questions were modified from the true/false format of Schwartz and Drager (2008) to “Agree,” “Disagree,” or “Uncertain.” In the next section (see Figure 2), “Effective Speech-Language Services for Children with ASD” questions were developed by investigators based on ASHA expectations for SLP roles and responsibilities (ASHA, 2016, n.d.-b) as well as tools considered to have emerging or established evidence (Bellini et al., 2007; Bopp et al., 2004; Goldstein, 2002; Koegel, 2000; LaRue et al., 2009; Mancil, 2009; National Autism Center, 2015). Responses for the first multi-item question, Question 10, addressing the importance of speech-language methods, included “Not Important (1.0),” “Minimally Important (2.0),” “Important (3.0),” and “Very Important (4.0).” Responses for the second question, Question 11, addressed SLP competency in using these tools when serving children with ASDs (see Figure 2). Response options included “Not Competent (1.0),” “Somewhat Competent (2.0),” “Competent (3.0),” and “Very Competent (4.0).” Together, these questions probed the groups’ perspectives regarding, first, the importance of assessment and intervention tools, and, second, the competency of SLPs in using these tools. Similarly, Question 12 was a multi-item question designed to assess the importance of SLPs’ knowledge, awareness, and effectiveness for core practices. Example questions included “Rate your knowledge of current trends and issues in the field of autism” and “Rate your effectiveness in communication with team members (the family, other educators, or service providers) for clients with autism spectrum disorders.” Responses used a Likert-type scale with the following options: Not Important (1.0), Minimally Important (2.0), Important (3.0), Very Important (4.0).

Figure 1.

Section 3, Characteristics of Autism, Question Nos. 2 to 9.

Figure 2.

Section 4, Question No. 10, “Effective Speech-Language Services for Children with ASD,” included importance ratings for select speech-language pathology methods considered part of best practices for SLPs.

Investigators developed the last section, titled “Autism Specialists,” for SLPs and parents to report their impressions regarding ASD expertise. First, they rated the likelihood that various providers (e.g., SLPs vs. psychologists or nurses) would have specialized skills for ASDs. Likert-type scale responses ranged from “Highly Unlikely” to “Highly Likely.” The SLP survey had a follow-up yes/no question that asked if SLP respondents identified as an autism specialist. The SLP group had a final multi-item question on a Likert-type scale (ranging from Strongly Disagree to Strongly Agree) composed of statements related to ASD specialists (e.g., “I usually like having assistance and direction from another professional or ‘autism specialist’ when developing appropriate programs for children with autism”).

Survey validity was addressed in two ways. Some items were adapted from prior studies that investigated ASD knowledge by SLPs (Cascella & Colella, 2004; Schwartz & Drager) or SLP preparation for another specialized population, traumatic brain injury (Hux et al., 1996). Most items were developed by the investigators, and face validity was addressed by expert and stakeholder review. Six faculty members from speech-language pathology and psychology reviewed both surveys, and two parents of children with ASDs reviewed the parent survey. Feedback resulted in improved descriptions for educational practices, survey setup, and the content and organization for demographic information.

Procedures

To ensure participant protection, the university IRB approved survey materials and procedures. Recruitment was initiated in the lower Alabama, northern Gulf Coast region of the United States. No attempt was made to conduct a national survey. Parents were recruited by word-of-mouth; from parent support organizations; and outreach via sending flyers home in the backpacks of children with ASDs enrolled in local, specialized schools. Community SLPs working in pediatric clinics or school systems were recruited via regional professional groups and by word-of-mouth. Estimates for the numbers reached during recruitment were 238 SLPs and 291 parents. Following recruitment, 63 SLPs and 33 parents initiated the surveys, response rates of 25% and 12% for the SLPs and parents, respectively. Three SLP and seven parent respondents were excluded because they completed the wrong survey or completed less than two thirds of the items. In total, there were 60 SLP participants and 26 parents.

Data Analysis

From Survey Monkey, responses were downloaded to Microsoft Excel spreadsheets and then imported to SPSS (IBM Corp, 2015). Question 1 data were categorical; therefore, proportions of parents and SLPs who responded similarly were calculated and chi-square tests were used to test group differences. Questions 2 through 4 consisted of Likert-type scale items converted to numerical scales. Descriptive statistics were means, standard deviations, and ranges. Analyses of variance (ANOVAs) with repeated measures were used to test for significant differences within and between groups, and Greenhouse–Geisser was selected to adjust for nonsphericity. Follow-up tests were conducted as applicable, and Bonferroni corrections were applied to decrease the likelihood of incorrectly rejecting the null hypothesis. Question 5 responses were summarized as percentages of SLPs for Likert-type scale categories. No within-group or between-group comparisons were conducted. Finally, t tests were used to investigate differences between SLPs who self-reported as ASD specialists and those who self-reported nonspecialists.

Results

To address the first research question regarding knowledge of ASD diagnostic criteria and associated characteristics, parents and SLPs responded to eight survey questions (see Figure 1). Only 52% (31/60) of SLPs and 44% (11/26) of parents were 100% accurate for Questions 2 through 5 regarding diagnostic criteria. Parents said “yes,” self-injury was an aspect of the diagnosis more often than the SLPs, and SLPs did not indicate that restricted, repetitive behaviors were part of the diagnosis as often as the parents. For Questions 6 through 9, 97% (58/60) of SLPs and 92% (23/26) of parents responded correctly. Parents were unsure about gross and fine motor deficits as an ASD characteristic, and they agreed “children with autism never make eye contact” more often than the SLPs. Chi-square tests of group differences were nonsignificant.

The second research question addressed the importance of assessment and intervention procedures considered best practices for children with ASDs as well as the competency exhibited by SLPs for these. SLPs and parents on average rated all assessment and intervention tools as Important to Very Important (see Table 1). The mixed model ANOVA/Greenhouse–Geisser revealed a significant main effect for the within-subjects factor of Importance, F(5.36, 428.64) = 3.70, p = .002. The between-subjects factor Group (SLP vs. Parent) and the interaction term (Importance × Group) were nonsignificant. Given the main effect, separate repeated measures ANOVAs were conducted for each group to test differences in Importance ratings. SLP Importance ratings (see Table 1) were significantly different, F(4.45, 244.81), p < .001; however, differences within the Parent group for Importance ratings were nonsignificant, F(4.57, 114.16) = 0.765, p = .566.

Table 1.

Parent and SLP Group Mean Ratings of Importance and SLP Competency for Surveyed Skills.

Importance and SLP competency measures	Parents			SLPs
Importance and SLP competency measures	M	SD	Range	M	SD	Range
Importance
Sign Language	3.19	0.98	1–4	3.30	0.85	1–4
Discrete Trial Training (DTT)	3.38	1.13	2–4	3.02^a	1.11	2–4
Applied Behavior Analysis (ABA)	3.62	0.90	2–4	3.50	0.60	2–4
Augmentative/Alternative Communication (AAC)	3.58	0.76	1–4	3.50	0.68	1–4
Functional Communication Training (FCT)	3.46	1.10	1–4	3.68^b	0.68	2–4
Milieu Teaching Paradigm	3.15	1.22	1–4	3.10	1.20	2–4
Social Skills Training	3.46	1.33	2–4	3.69	0.50	2–4
Nonstandardized Observation Measures	3.46	1.24	1–4	3.36	1.01	2–4
Competency
Sign Language	2.73	1.40	1–4	2.60^c	1.03	1–4
DTT	2.92	1.23	1–4	2.92	0.93	1–4
ABA	3.04	1.11	1–4	2.71^c	0.89	1–4
AAC	3.04	1.22	1–4	2.77^c	0.87	1–4
FCT	2.96	1.22	1–4	2.75^c	1.13	1–4
Milieu Teaching Paradigm	2.73	1.28	1–4	2.77	1.11	1–4
Social Skills Training	2.84	1.21	1–4	2.88^c	0.76	1–4
Nonstandardized Observation Measures	2.62^d	1.41	1–4	2.95^c	0.79	2–4

Note. Significant items marked in bold. Likert-type scales items were Not Important/Competent (1.0), Somewhat Important/Competent (2.0), Important/Competent (3.0), and Very Important/Competent (4.0). SLPs = speech-language pathologists.

SLPs rated DTT significantly less in Importance than FCT or Social Skills Training. ^bSLPs rated Importance of FCT significantly more than Milieu Teaching Paradigm. ^cSLPs rated their Competency significantly less (p < .006) than Importance for six of the eight skills. ^dParents rated Importance significantly higher than SLPs’ Competency for Nonstandardized Observation Measures.

Of particular interest for Research Question 2 were differences between Importance ratings and SLP Competency ratings. Although Importance and Competency are separate constructs, Likert-type scales were created to rate them similarly (e.g., 2 = Somewhat Important and Somewhat Competent) and eight paired samples t tests with a Bonferroni correction were conducted within each group. When comparing SLP ratings, statistical significance was found for six of the eight practices (see Table 1). For these, SLPs rated practices as Important or Very Important but rated their competency as only Somewhat Competent. Parents’ perceptions of importance and SLP competency revealed one statistically significant difference: Parents rated use of nonstandardized assessments and observational methods as significantly more important than SLP competency for this skill.

For the third research question, SLPs’ and parents’ ratings of the importance of SLPs’ knowledge and effectiveness for educational practices associated with ASD were compared (see Table 2). Parents rated all as Important to Very Important, means of 3.5 or higher. Similarly, SLPs rated five of the eight 3.5 or higher. The mixed model ANOVA/Greenhouse–Geisser revealed a significant main effect for the within-subjects factor Educational Practice and the interaction term Educational Practice × Group. To understand differences for educational practices within groups, separate group ANOVAs were conducted. Despite a significant main effect of Importance for the Parent group, F(2.55, 63.80) = 3.53, p = .025, pairwise comparisons were not statistically significant. This was most likely because of consistently high ratings for all eight. For the SLP group, a significant main effect of Importance was revealed, F(4.96, 282.53) = 7.80, p < .001, and statistically significant pairwise comparisons are shown in Table 2. Eight independent samples t tests were conducted to test group differences, given the significant interaction and results are shown in Table 2.

Table 2.

Parent and SLP Perceptions of the Importance of Educational Practices Associated With ASDs.

Practice	Parent			SLP
Practice	M	SD	Range	M	SD	Range
ASD characteristics	3.92	0.272	3–4	3.75^a	0.628	3–4
Current trends	3.85^b	0.368	3–4	3.43	0.722	2–4
Identification process	3.50	0.860	3–4	3.32	0.797	2–4
Ongoing assessment	3.92	0.272	3–4	3.69	0.650	3–4
Health and medical issues	3.69	0.884	2–4	3.63	0.688	2–4
IEP/IFSP development	3.92^b	0.272	3–4	3.48	0.911	1–4
Team member communication	3.92	0.272	3–4	3.85^a	0.577	3–4
Counseling parents	3.65	0.846	3–4	3.68	0.676	2–4

Note. Significant items marked in bold. Ratings based on a Likert-type scale: Not Important (1.0), Somewhat Important (2.0), Important (3.0), and Very Important (4.0). SLPs = speech-language pathologists; ASDs = autism spectrum disorders; IFSP = Individualized Family Service Plan; IEP = Individualized Education Program.

SLPs rated team member communication and knowledge of ASD characteristics significantly more important than knowledge of current trends and educational identification process. ^bImportance ratings by parents for knowledge of current trends and for IEP/IFSP development were significantly higher than ratings by SLPs.

The fourth research question addressed perceptions of SLPs and parents regarding which professions are likely to be ASD specialists. Respondents rated the likelihood of 10 professions being ASD specialists (see Table 3). The ANOVA (10 Professionals × 2 Groups) revealed a significant main effect of Professional, F(6.60, 514.84) = 30.84, p < .001, and a significant interaction effect for Professional × Group, F(6.60, 514.84) = 2.471, p = .019. Significant findings from follow-up pairwise comparisons/Bonferroni correction and independent samples t tests are shown in Table 3. Next, for Research Question 5, the SLPs, but not parents, rated statements regarding their access to or work with ASD specialists and their consideration of becoming an ASD specialist (see Table 4). All said that children in schools could benefit from an ASD specialist, and 98% agreed they would collaborate with an ASD specialist if available. Furthermore, 70% said they would be interested in becoming an ASD specialist, even if that meant additional academic training.

Table 3.

Parents’ and SLPs’ Ratings and Rankings for Likelihood of Providers Being Autism Specialists.

Provider	Parent				SLP
Provider	M	SD	Range	Rank	M	SD	Range	Rank
Pediatrician	3.20	0.96	1–4	7	3.02	0.71	1–4	6
Nurse	2.96^b	0.94	2–4	9	2.32	0.78	1–4	10
Neurologist^a	3.64	0.59	2–4	3	3.62	0.56	2–4	3
OT	3.44	0.77	2–4	5	3.42	0.68	2–4	5
SLP^a	3.64	0.64	2–4	3	3.71	0.49	2–4	2
PT	2.80	1.00	1–4	10	2.98	0.71	1–4	7
Psychologist^a	3.73	0.67	1–4	2	3.58	0.59	2–4	4
Counselor	3.16	0.99	1–4	8	2.85	0.72	2–4	9
Educator/Teacher	3.24	0.93	1–4	6	2.98	0.76	1–4	7
Behavior Analyst^a	3.83	0.49	2–4	1	3.75	0.44	3–4	1

Note. Significant items marked in bold. Likert-type scale: Highly Unlikely (1.0), Not Likely (2.0), Likely (3.0), and Highly Likely (4.0). SLPs = speech-language pathologists; ASD = autism spectrum disorder; OT = occupational therapist; PT = physical therapist.

SLPs rated four professionals significantly more likely to be ASD specialists than others. Similarly, parents’ ratings for the four were significantly higher than for nurses and PTs. ^bNurses were rated significantly more likely to be ASD specialists by parents than SLPs.

Table 4.

SLP Perceptions Regarding Access to, Use of, and Future Option of Being an ASD Specialist.

Statement	Strongly disagree1.0	Disagree2.0	Agree3.0	Strongly agree4.0	Not sure	M (SD)
I usually like having assistance and direction from another professional or “autism specialist” when developing appropriate programs for children with autism.	0% (0)	8% (5)	48% (29)	42% (25)	2% (1)	3.28 (0.76)
I feel that I have enough clinical and educational training to deliver effective intervention to children with autism.	0% (0)	25% (15)	60% (36)	13% (8)	2% (1)	2.83 (0.72)
I feel that I could have benefited from receiving additional coursework and training in the area of autism.	0% (0)	8% (5)	50% (30)	42% (25)	0% (0)	3.33 (0.63)
I feel that children in public school systems could benefit from access to autism specialists.	0% (0)	0% (0)	33% (20)	65% (39)	2% (1)	3.60 (0.67)
If I knew that I could work with or have access to an autism specialist, I would use that person as a resource.	0% (0)	2% (1)	41% (24)	58% (34)	0% (0)	3.56 (0.53)
I would be interested in becoming an autism specialist even if that meant participating in additional academic training.	7% (4)	23% (14)	33% (20)	32% (19)	5% (7)	2.80 (1.12)

Note. Frequencies are reported in percentage of respondents (number of respondents). The most frequent response category is given in bold. SLP = speech-language pathologist; ASD = autism spectrum disorder.

When SLPs were asked if they considered themselves ASD specialists, 19% agreed. This unplanned finding led to a post hoc analysis of data with the SLP group divided into ASD Specialists and Nonspecialists. ASD Specialists reported having sufficient clinical and educational training compared with those who were Nonspecialists, t(56) = 4.03, p ≤ .001. This perception was despite nonsignificant group differences (p > .006) in degree-based training and continuing education. Instead, specialists reported a significantly higher number of children with ASD on career caseloads than Nonspecialists, 21 to 25 compared to 11 to 15 individuals, respectively, t(42) = 2.60, p = .013. When key survey responses were examined for the specialist subgroups, ASD Specialists were significantly more accurate for understanding ASD characteristics, Questions 6 through 9, t(46) = 3.51, p = .001, than Nonspecialists, 100% and 93%, respectively. In addition, ASD Specialists had competency self-ratings significantly higher than Nonspecialists for two tools: milieu teaching, t(56) = 3.01, p = .004, and nonstandardized measures and observational methods, t(56) = 2.86, p = .006.

Discussion

This study was the first to compare directly survey responses of SLPs and parents regarding critical components of effective speech-language practice with children with ASDs, and findings illuminate the practice gap between SLP preparation and expectations for SLP expertise serving children with ASDs and their families. The first finding was that only about 50% of SLPs answered questions about ASD diagnostic criteria accurately. This result was surprisingly low; after all, surveyed SLPs had pediatric experience and the majority worked in schools. Knowledge for defining ASDs was not significantly different for parents compared with SLPs, but it is not parents’ responsibility to identify ASDs. Imagine the impact of not having sufficient ASD knowledge by pediatric SLPs when 1 in 59 U.S. children are diagnosed with ASDs by age 8 years and parents report speech-language therapy as the highest frequency service. It is critical that SLPs in pediatric settings acquire a strong understanding of ASD diagnostic criteria because often it is SLPs who first see late-talking children. A lack of knowledge by SLPs can delay developmental evaluations. Although ASD diagnosis can be accurate for 2 year olds, most children are evaluated after age 3 years and are not diagnosed until after age 4 years, too late for early intervention.

Our estimate of SLPs’ knowledge of ASD represented an improvement compared with Schwartz and Drager (2008). SLP accurate responding for the core feature of social interaction impairment was 97%, up from 79% reported by Schwartz and Drager, and for restricted, repetitive behaviors was up to 73% compared with their 52%. Course work has increased over time (Plumb & Plexico, 2013), a likely factor supporting increases in SLP knowledge. Plumb and Plexico, however, found that SLPs who had been out of school longer were more knowledgeable than recent graduates, implying that continuing education and experience were critical components. Our findings also suggested that experience was more important than formalized continuing education. Our SLP specialist subgroups did not report significantly different preprofessional training or continuing education. Instead, ASD specialists reported significantly larger career ASD caseloads compared with nonspecialists. Differences seemed small: career caseloads of 20 or more compared with an average of 11 to 15 career clients. Do SLPs who have served 15 to 20 clients with ASDs, begin to acknowledge their expertise? Perhaps increased experiences lead SLPs to undertake independent study, not reported as continuing education. Serving even a few more children, given ASD heterogeneity, may broaden SLP knowledge.

A second finding was that SLPs rated their competency for ASD practices as significantly lower than their importance ratings, confirming our hypothesis that SLPs lacked confidence for specialized skills needed to effectively serve children with ASDs. In particular, SLPs indicated lower competence for applied behavior analysis and functional communication training but not the behavioral methods of discrete trial training or milieu teaching. We judged this result to be due to lower importance ratings, not lower competency ratings, for discrete trial training and milieu teaching. We argue that SLPs do not have sufficient knowledge to accurately judge importance, especially for milieu teaching. Consistent with our interpretation, significant differences were found for ASD specialists’ competency self-ratings compared with nonspecialists’ self-ratings for milieu teaching. Findings are noteworthy because milieu teaching is an evidence-based treatment for children with ASDs (e.g., Kaiser & Yoder, 1992; Mancil, 2009).

The ASD specialists also reported higher self-rated competence compared with nonspecialists for nonstandardized measures and observational methods. This leads us to the one significant difference between parents and SLPs when rating SLP competency. Parents of children with ASDs perceived SLPs’ competent use of nonstandardized and observational methods significantly lower than parent-rated importance. Parents may know that standardized test procedures create difficult testing environments and unrealistic standards for their children with ASDs. In direct conflict with parents’ perceptions were the SLP group’s relatively higher self-ratings for nonstandardized and observational methods compared with competency for other skills. We propose that despite competence, SLPs tend to overrely on standardized assessments for several reasons. One factor is the interpretation of federal laws that lead to almost exclusive use of standardized assessments for service eligibility and progress monitoring in school settings. A second factor is preprofessional training that traditionally emphasizes administering standardized tests. And finally, nonstandardized and observational methods are deemed too time-consuming to be undertaken by busy school-based SLPs. A reexamination of nonstandardized and observational methods is worthwhile, and improved training could increase efficient use.

One of our more revealing findings was that SLPs rated the importance of Individualized Education Program (IEP)/Individualized Family Service Plan (IFSP) development significantly lower than parents of children with ASDs. SLPs, 74% of whom worked in schools, did not value the IEP/IFSP development process at the same level as parents. For parents, IEP/IFSP development often consists of one annual meeting with team members to discuss current functioning, goal areas, and accommodations. This yields high stakes for parents, unlike SLPs who participate in many IEP/IFSP meetings. Perhaps familiarity for SLPs results in reduced appreciation inconsistent with parental expectations. White (2014) investigated state-level school system complaints filed between 2004 and 2009 by parents of children with ASDs and found that almost three fourths listed the IEP process as the problem.

SLPs also rated the importance of knowledge of current trends significantly lower than the parents of children with ASDs. One reason may be that SLPs know that some trends (e.g., use of hyperbaric oxygen or glutathione supplements) are not part of their practice. In fact, it is SLPs’ responsibility to avoid recommending treatments with no evidence, or worse yet, considered not effective (e.g., ASHA, 2018 position on facilitated communication). We are not suggesting that SLPs engage in discredited practices; however, SLPs can listen and counsel parents seeking information and deciding how to allocate resources. For this reason, SLPs need to stay abreast of information available to families of children with ASDs.

The last consideration is the need for ASD specialists. Clearly, SLPs and other professionals serving children with ASDs can be better prepared, but the appropriate level of preparation needed, a combination of preprofessional course work and clinical practice plus work experience and continuing education, is unclear. SLPs surveyed indicated that they would use the support services of an ASD specialist in schools, and the majority indicated a willingness to develop ASD specialty with training. Third-party certification processes, like IBCCES or the SLP Specialty Board Certification in development with ASHA, cost hundreds of dollars initially and annually on top of other annual certification and licensure costs. Furthermore, there has been no research regarding the impact of ASD specialists compared with nonspecialists on the quality of services or outcomes for children with ASDs.

Study limitations are primarily associated with the sample. Recruitment focused on a relatively small region with established practice gaps—Campbell et al. (2007) found that the average age of ASD diagnosis in Alabama is 6 years and 23% of those diagnosed received the diagnosis outside of the state of Alabama—Our survey recruitment relied on convenience sampling, limiting comparisons between the sample and the population. Some of our demographic findings support generalization to the population. Specifically, the age, gender, and educational background of participants were in keeping with expectations for the greater population of SLPs and mothers. It is possible, however, that survey participants have a vested interest in ASDs. One indication of this was the relatively high number of SLP respondents, 19%, who considered themselves ASD specialists. Also, groups were not aligned: The parents of children with ASDs were not necessarily being served by the SLPs surveyed. Notwithstanding limitations, this investigation provided a direct comparison of parents’ and SLPs’ perceptions in a region of the United States struggling to support the needs of the ASD community.

Conclusion

SLPs, despite their substantial role in serving children with ASDs and their families, continue to report being underprepared for ASD-specialized knowledge and skills. Both SLPs and parents exhibited weaknesses for correct identification of ASD defining features. SLPs said they are only somewhat competent for skills they considered very important. Parents generally reported that SLPs were competent, except for the use of nonstandardized and observational assessments. Also, SLPs’ ratings of importance were lower than parents’ ratings for the IEP/IFSP process and knowledge of current trends. Finally, SLPs who were ASD specialists demonstrated more knowledge and greater competence than nonspecialists. Findings make clear the need for improved training for SLPs, including consideration of the need for ASD specialty, with the aim to deliver maximally effective speech-language services for children with ASDs.

Footnotes

Acknowledgements

We would like to thank the participants and acknowledge the contributions of colleagues: Kelli J. Evans, Julie M. Estis, Lisa A. Turner, and Sean T. Stalley.

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

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