Swedish speech and language pathologists reflect on how their clinical practises align to everyday language and communication skills of children with developmental language disorder

Abstract

This study aims to extend current knowledge about the possibilities and challenges encountered by Swedish speech and language pathologists (SLPs) in targeting everyday language and communication in children with developmental language disorder (DLD). To explore this matter, unstructured focus groups were conducted where 15 SLPs, working with children with DLD, shared their views on the alignment between their clinical practices and children’s everyday lives. Thematic analysis was used to analyse the data, which resulted in five themes: It’s everyday life that matters; As an SLP, you’re not a part of the child’s everyday life; How do we merge the different worlds?; Resources at home vary, and The employer sets the framework for clinical practices. The SLPs stressed the importance of targeting everyday skills and needs, but they experienced themselves as being detached from the children’s daily context. Collaboration with caregivers and (pre)school staff was emphasised; however, the resources and capacity of the caregivers and staff varied, and this was experienced as a challenge for providing the most appropriate care. Some children and their families were situated in a multifaceted context and needed more extensive care, and this group was described as increasing. However, the services that the SLPs were able to offer varied and were largely regulated by organisational constraints. Individualised services are crucial for ensuring a positive development for children with DLD and for empowering caregivers to be effective collaborative partners in intervention. Therefore, it is essential for SLPs to have the time and resources to ensure high-quality care.

Keywords:

• Developmental language disorder
• speech and language pathology services
• children
• ecological validity

Introduction

Developmental language disorder (DLD) is a prevalent neurodevelopmental disorder that affects approximately 8% of all children [1] with different language and communication difficulties, with various degrees of severity [2]. The difficulties impact children’s daily lives in different ways, for example as challenges in interacting with peers [3] and poor academic achievements [4]. DLD occurs in children across the population, but factors that have been highlighted as increasing the risk of DLD are family history of language disorder or dyslexia [2,5], and growing up in a socially disadvantaged area [6,7]. A recent study by McGregor et al. [8] showed that what predicted the level of the disability was not the severity of language impairment measured by decontextualised language tests, but an accumulation of risk factors (socioeconomic status, nonverbal IQ, and other health conditions). Furthermore, despite the fact that multilingualism is not a risk factor for DLD, children with one or two immigrant parents are at greater risk of getting a language disorder diagnosis [9,10]. Hence, a range of children and families are referred to speech and language pathology (SLP) services for DLD. To effectively support the children’s development, it is crucial that they are offered individualised care that is linguistically and culturally adapted [11].

An essential part of SLP services for children with DLD is cooperation with people in the child’s social network, such as family members and members of staff at (pre)schools. It is important that there is collaboration and shared-decision-making between the SLP and caregivers, to certify that there is an alignment between the intervention, and the child’s everyday skills and needs [12,13]. A successful collaboration requires that caregivers are empowered in a constructive and supportive way [14,15]. However, caregivers’ expectations on, and engagement in language intervention vary [16,17]. The degree to which they want to be active in clinical decision-making may also differ [18]. Furthermore, studies indicate that SLPs tend to view caregivers as ‘helpers’ tasked with e.g. carrying out homework activities prepared by the SLP, rather than being viewed as ‘co-interveners’ [19,20]. Previous studies have also identified challenges in the collaboration between SLPs and teachers, arising from differences in terminology and views of what DLD encompasses [21,22].

In studies exploring caregivers’ views on language treatment outcomes, improved everyday abilities and social inclusion are reported as a primary wish [23,24]. In a study by Morgan et al. [25], the majority of SLPs reported it as essential that the skills acquired in treatment were usable and meaningful in the child’s everyday life. Nevertheless, research has indicated that these intervention outcomes are rarely evaluated [13,26]. Jensen de López et al. [23] propose that there is a discrepancy between the everyday functionality requested by caretakers and SLPs’ domain-based (e.g. syntax and morphology) practices. Furthermore, it has been argued that SLP practices to a large extent treat communication as an individual ability detached from the social context, rather than recognising it as a collaborative process occurring within interaction [27].

Organisational constraints seem to have a large impact on how SLP treatment is structured [28]. In Sweden, the SLP services offered to children with DLD, and their families are largely determined by the child’s age. Services for young children with DLD (up to 6 years) are carried out within the healthcare system, most often at an SLP clinic in a hospital. At the clinic, the SLPs assess as well as carry out treatment [29]. An increasing number of SLPs are now also becoming employed within preschools and schools. Their primary task is to support pupils in reaching the goals of the curriculum [30]. For school-age children with DLD (6–19 years), the healthcare system as well as the educational system are legally obligated to provide services [31,32]. However, in reality, the Swedish health care system only conducts assessments for school-age children with suspected DLD, while intervention is primarily delivered by the educational system [33]. Thus, support is mainly provided by teachers and/or special educators, and by SLPs, when accessible [29]. It is not mandatory by law to provide SLP services in the Swedish education system, and therefore the number of SLPs who work within the preschool and school system is still limited [34].

Several studies emphasise the importance of SLP services addressing language and communication aspects that are relevant to and aligned with the everyday lives of children with DLD and their caregivers [e.g. 23,25,35]. Investigations have, for example, examined SLPs’ views on their own and caregivers’ roles [19] and on caregivers’ engagement in intervention [17,36]. These are factors that are essential for ensuring a strong alliance between the SLPs and the people who surround the child. However, to our knowledge, no studies have so far been conducted that target how SLPs perceive that their practices align or not with children’s communication needs in everyday life. Knowledge about SLPs’ views on their own conduct and its applicability outside of the clinic may contribute new insights of importance for developing SLP services, and make clinical practices for children with DLD further individualised, relevant, and ecologically valid.

Aim

The aim of the present study is to extend current knowledge about the possibilities and challenges of Swedish SLP practices in terms of if and how they target everyday language and communication. Focus groups were used to investigate SLPs’ views of the alignment between their clinical practices and the everyday lives of children with DLD.

Method

A total of 15 SLPs participated and were divided into three groups consisting of four, five, and six persons. An attempt was made to achieve diversity regarding the geographical location of their workplaces. The focus groups were carried out and recorded via Zoom [37] with the first author acting as a moderator.

All participating SLPs had expressed an interest in taking part in the present study when completing a questionnaire that dealt with clinical practices for children with language disorders [38]. They were thereafter contacted by the first author, who provided written information about the study and an offer to give further information over the phone. The SLPs gave their written consent to participate. Inclusion criteria to participate were to be an SLP working clinically in Sweden with children with DLD. The participating SLPs were all female, and their working experience ranged between 1 and 19 years. In terms of geographic affiliation, 9 of the 21 regions in Sweden were represented by at least one SLP. See Table 1 for an overview of the participants.

Table 1. Overview of the participants in codenames in each focus group regarding workplace and the number of years as an SLP working with children with DLD.

Group	Participant	Workplace	Years active as an SLP working with DLD
1	Alice	SLP clinic	8
	Joanne	SLP clinic	2
	Kate	Preschool	16
	Ruby	School	1
	Sarah	Specialist preschool for children with DLD	11
2	Chloe	SLP clinic	5
	Emma	SLP clinic	2
	Maria	SLP clinic	13
	Olivia	SLP clinic	8
	Victoria	Hearing care centre	1
	Zoe	Specialist school for children with DLD	11
3	Amanda	SLP clinic	9
	Catherine	SLP clinic	15
	Evelyn	SLP clinic	19
	Lucy	SLP clinic	3

The discussions started with the participants introducing themselves to each other in the group, and the moderator gave oral information about practical matters, for example the estimated time frame and study ethics, such as confidentiality. After this, participants were presented with the topic for the discussion: Clinical SLP practices for children with DLD, with a focus on the alignment with the children’s language and communication skills in everyday life. The discussions that followed were unstructured [39,40], which meant that the participants were free to reflect upon and explore the topic at hand with little or no involvement by the moderator. The discussions ranged from 1 h and 33 min to 1 h and 36 min.

Analytical procedure

The interviews were transcribed verbatim, and the analysis was conducted using reflexive thematic analysis (TA) [41,42]. TA was considered suitable since it allows for an inductive approach to identify patterns of meaning across the dataset. Furthermore, TA offers a flexibility for both semantic and latent coding, hence enabling descriptive as well as interpretive analysis of the data [42]. In this study, a semantic approach for coding was used.

To get familiarised with the data, the transcriptions were read through repeatedly, and the video recordings were reviewed. Segments referring to the topic of the study were, as a second step, identified and provided with a coding label. Thereafter, all the codes were scrutinised in order to identify meaning patterns, and initial themes were developed. These first steps of the analysis were carried out by the first author, and then scrutinised, reviewed, and discussed collectively by all authors until consensus was reached. The naming of the themes was also mutually agreed upon during the review process.

The focus group discussions were carried out in Swedish, and consequently so were transcriptions. The extracts that are used to exemplify and illustrate the themes in the results section were translated into idiomatic English after analysis. Passages that were not relevant for illustrating the theme at hand, were marked with […].

Researcher positioning

Three of the authors, including the moderator, are SLPs with backgrounds as clinical practitioners working with children with DLD. In addition, the group has extensive experience in conducting qualitative research on children with DLD, as well as with people with language and communication difficulties at large. To have a background as an SLP inevitably influences the interpretation of the data, since experience of clinical practices may contribute to assumptions about the area. Throughout the process, it was therefore important to reflect upon subjectivity and positioning and their potential effects on analyses and interpretations of the data. In order to ensure that the focus group discussions were not influenced by potential prior expectations on the topic, the discussions progressed with a minimum of interference or feedback from the moderator.

Results

Analysis of the data generated five themes. The first three themes concerned the SLPs’ views on the relationship between SLP services and the children’s everyday life: It’s everyday life that matters; As an SLP, you’re not a part of the child’s everyday life, and How do we merge the different worlds?. The last two themes focused on cooperation with caregivers and the impact of the employer: Resources at home vary, and The employer sets the framework for clinical practices.

It’s everyday life that matters

The discussions in the focus groups recurringly addressed the fact that SLP services aim to positively affect the child’s everyday life. At the same time, several of the SLPs stated that they often struggled with formulating intervention goals that targeted everyday functioning. A few SLPs expressed that they formulated more generic, yet aspiring goals: ‘I don’t usually set explicit goals, but more like, now we’re going to try to discover this language sound’ (Emma). The SLPs who stated that they usually formulated goals, reflected on the difficulties associated with finding goals that were of importance for the child’s communicative needs in everyday life. Alice, who worked in an SLP clinic, said:

Yes, exactly the functionality. Because there’s so much talk about, well about colours and different words and all that. Sure, colours are good to know, but how interactive is that if you kind of want to get a response from a friend?

Everyday life was also discussed as the child’s primary resource for language stimulation. The SLPs emphasised that the treatment that was offered at the clinic was not enough to solve the children’s difficulties, and that it was crucial that the treatment was also conducted by caregivers and (pre)school staff in settings outside of the clinic. Ideally, the SLP was not the person to carry out the treatment. Instead, the SLP was considered a specialist, whose role was to guide people in the social network of the child:

I want to make myself as much, what should I say, as unimportant as possible for the child […] I want it to happen, that it mainly should happen in the preschool and in the child’s play and where she or he is. Then I can go in and like provide some support, like being the icing on the cake maybe. […] and maybe practice those specific things that don’t occur at the preschool. But the main thing isn’t that I come with vocabulary and practice words and such things. That’s something that the children must get where they spend most of their day. (Sarah)

Additionally, one suggestion that was put forward was that intervention goals could possibly be more focused on the behaviour of people surrounding the child and aspects of the child’s context, rather than solely on the child. This was suggested to decrease the pressure on the child and the child’s performance, and instead highlight the importance of language stimulation. It was expressed as essential that caregivers were to understand their role in intervention, and that they were made aware of strategies to stimulate the child’s language in everyday activities. Empowering caregivers was stressed as a central part of intervention, due to many caregivers not trusting themselves to be able to help their children.

As an SLP, you’re not a part of the child’s everyday life

The second theme concerned the SLPs’ views of being in a role and setting that were far from the child’s daily life. The SLP clinic was described as estranged from a naturalistic context, whether it was in a hospital or at a (pre)school. Generally, this was expressed as a disadvantage. Catherine, situated at a SLP clinic, described how the clinical setting might limit assessment:

It’s not the ideal environment for understanding the way the child actually functions. Whether they open up or not varies a lot, and the environment is artificial. We do weird things. You want to know what it’s like at home and what it’s like at preschool.

Not being able to act outside of the clinic was sometimes perceived as frustrating, and there was a feeling that information that might be important for the intervention was missed out. The SLPs who currently worked or had previously worked in (pre)schools experienced that there was sometimes a discrepancy between descriptions originating from language tests and the functionality of the children in their everyday environment. Some children were described to function well despite their difficulties, while some were perceived as heavily affected by their impairment: ‘one language profile may take very different forms in everyday life’ (Kate). The environment was discussed as essential for the child’s functioning and performance, and for the different demands brought onto the child. Such differences were challenging for the SLPs when trying to form an overall picture of the child and when guiding caregivers concerning indirect treatment. The wish for an increased access to the children’s everyday lives and the feeling of ‘sitting in my little island’ (Kate) evoked reflections:

It’s easy for me to just focus on certain activities and do them at my place, to bring out this game or this material, and I know we can practice a lot of linguistic aspects there and then. But it must also relate to what goes on in the child’s everyday life overall. And I think that gap, I sometimes really struggle to manage it, or like, to overcome it. (Sarah)

Another challenge about being distanced from the child’s everyday life was how to ensure that the child generalised the skills practiced at the clinic into everyday language: ‘But it’s still, I think, difficult sometimes that what the child does with me in my room that, even if it’s just one step outside the door, to make them remember it. To continue using it is super tricky’ (Zoe). Both generalising the abilities and assessing if the skills were being used outside of the clinic were described as almost impossible without collaboration with caregivers and/or (pre)school staff.

Even though the SLPs expressed a concern of feeling detached from the children’s mundane life, the disconnection was not always described as an obstacle:

If you meet a child, like who has a bit of a hard time making himself understood, then it’s like only I who understand what it is that’s going on with the sounds and what we need to practice in order for it to get better, and then it becomes more this classic SLP. It’s actually quite disconnected from reality when you practice, if you only practice pronouncing predetermined images and so on. But the goal is like for the child to be more easily understood, and he will be, if he breaks stopping and fronting, that is. (Joanne)

In cases like the one described by Joanne above, the SLP was depicted as an expert that pinpointed the child’s difficulties and delivered specified interventions for the problems. Solving those problems was argued to affect the child’s everyday life in a positive way, even though the intervention itself was detached from real life. Some problems, for example grammar and phonology, were described as easier to target in this more clinical approach than greater impairments and difficulties with language comprehension. This approach to SLP services was discussed as typical for traditional SLP practices that have a modular orientation and working material within different linguistic abilities such as grammar, vocabulary, and phonology.

How do we merge the different worlds?

The third theme reflected the SLPs’ talk about how families, (pre)schools, and SLPs belonged to three different parts of the child’s world, and how to overcome the gap that appeared to exist between them. Caregivers, teachers as well as special educators were emphasised as highly valued cooperation partners but there was a wish for a more seamless relationship. Ideally, (pre)school staff were thought of as an important part of the collaboration around the child, but in reality, both the quality and the quantity of the cooperation with (pre)school staff were said to vary greatly:

It is very unequal depending on which municipality you live in, and the degree of interest in having a contact with an SLP depends on the individual special educator, I would almost dare to say. If they are interested and like ‘what is this?’, and ‘is it a language disorder?’, and ‘how can we work with it at the preschool?’. Or is it like, ‘no we’re doing our things, you can do yours’. (Amanda)

Regarding the cooperation with caregivers, it was discussed that the image of the child that caregivers express quite often differs from that of the SLP. The caregivers’ descriptions may deviate from the SLP’s assessment as well as from the information provided by (pre)school staff. The SLPs also expressed difficulties fully connecting with caregivers and to get their message across: ‘it feels like our worlds are so far apart […] you try to explain what language is and so on, but it’s very abstract, usually disconnected from what they are thinking about’ (Joanne). An experience of ‘I have my image and they have theirs’ (Joanne) was also expressed regarding the cooperation with teachers and special educators, and it was discussed as sometimes a challenge to overcome that gap. Kate (working at a preschool) and Alice (working at an SLP clinic) stated:

Kate: That’s to a great extent what I do, I try to understand like ‘this is what the SLP says, and you tell me this, and how does it all go together? What are you like thinking together?’ […]

Alice: The fact that there may be a need for, like a mediator is interesting. That is, for someone to convey, the fact that there is a need for a person as an SLP between the SLP at the clinic and the pedagogues. Because it’s not always the case, even if you have contact with the special educators and the teachers over the phone, that you get these different values to merge.

The need for a mediator between the clinic and (pre)school staff was raised multiple times by the SLPs working at a clinic. SLPs situated at (pre)schools were emphasised as their ideal cooperation partner that could function as such a mediator. A large part of the contact with (pre)school staff today was described to be ‘very much about informing what a language disorder is’ (Catherine). The process of making staff aware of the child’s difficulties and explaining the difference between language and situational comprehension was deemed as essential. Furthermore, some of the SLPs experienced that (pre)school staff had a view of language stimulation as something that was carried out as a task, and something that was detached from the regular activities. Staff regularly asked for material to use with the child, but the SLPs stressed ‘it’s not the material that’s important, but rather the way you do it’ (Evelyn). The different views about the child’s skills and difficulties, as well as on what language stimulation were and how it was to be carried out, were expressed as challenges to overcome. Solving this issue might require a different role of the SLP, and different kinds of working methods:

What does the SLP do alone in his/her chamber versus building relationships with the educators? Getting them to understand and sort of look through the same lenses and understand this sudden moment when you can actually stimulate language […] it’s very difficult, but I think that’s what we have to do. But it’s really not measurable and like ‘check’, but a long, slow job. (Kate)

Resources at home vary

The fourth theme illustrated cooperation with caregivers, and factors that affected that collaboration. The children that were enrolled at the SLP clinic were described as having changed over the years, and so had the everyday environment around the children. Catherine reflected on the challenges that this brought with it:

It has changed a lot during the time I’ve been working, that we’ve gone from having monolingual 4 to 5-year-olds to having multilingual 2.5-year-olds who have no language and hardly any communication. And that is like, our children today have an entirely different complexity, like their difficulties and their language and everyday life and communication environments are so different, and the parents have a completely different capacity in what they can take on. And I feel like we stand a little more downcast, because these intervention methods or like what we learned at university once upon a time, do not really correlate with what reality looks like today.

In addition to the increased complexity regarding the children and their everyday context, the degree to which the child had been exposed to the different languages (s)he possessed was expressed as a challenge. The assessment was described to be further complicated when the children attended preschools with few individuals speaking Swedish as their first language: ‘what do we do with those children who have no Swedish at all at home and who are in a preschool with no monolingual children, none, whose first language is Swedish, with staff whose first language is not Swedish? They get very little Swedish. How are we to be able to judge what it is?’ (Catherine).

It was considered as a challenge to meet every individual at their own level, and to adjust the intervention to each family:

It can be very tricky because, not so much the language problem but the socio-economic one, like that some parents have such a low level of education themselves […] you need to adapt to that level, and it can be very difficult to know like who the parent is that you have in front of you. Like, how well educated they are, some are, have a higher education than I do from their home country and others are, can’t read or write. (Olivia)

Being explicit and concrete was stated as key elements in coaching the caregivers. Instructing them how to use everyday situations, such as doing laundry, to stimulate language was brought up as a typical strategy. Involving the child’s broader network, such as siblings, into delivering intervention was also highlighted as beneficial. The experiences were that there was a need for a lot of repetition, both regarding how to stimulate language and for explaining the child’s difficulties.

Caregivers were throughout the discussions described as a vital and central source of information when it came to both assessment and evaluation. When working with multilingual children, parental reports formed the basis for assessment: ‘I rarely assess the home language, so it is really the parents’ statement’ (Emma). However, the SLPs described how it was sometimes hard to know how to interpret the caregiver’s statements regarding the child’s skills and difficulties - for both mono- and multilingual children. Above being crucial for getting access to the children’s everyday functioning, caregivers had a large impact on the intervention. It was therefore perceived as troublesome for the SLPs when there were uncertainties whether the information provided was in line with reality or not:

I also feel that, when I ask the parents, that I am not always completely sure that they tell the truth, but sometimes I can, some can probably say, that is, say that it’s worse than it is. And some might say it’s better than it is. I get the feeling that they don’t really know or like, that they’re a bit unsure. And then I’m unsure if that’s true or not. (Maria)

The sometimes uncertain descriptions from caregivers were discussed to be due to the caregivers lacking awareness about language use and development in general. They might also make misleading comparisons with other children and ‘put other values in what is good and, or capable’ (Sarah). The SLPs witnessed of caregivers declining treatment because of these inaccurate perceptions, even though the assessment showed that the child had extensive difficulties. When caregivers were believed to have misrepresentations about what was “typical” or not, one point was to try to raise a concern in order for the caregivers to ‘formulate their need for care’ (Olivia). This was described as entitled because of the caregivers’ right to decline care if they did not find it necessary. Some SLPs even stated that ‘it can be a bit of, like a treatment goal’ (Olivia) in its own, in order for the child to continue receiving SLP services.

The employer sets the framework for clinical practices

The fifth and last theme revolved around the fact how the employer forms the structure for the services and the collaborations with the child’s social network. Several of the SLPs who worked at a clinic described their practices as relatively structured, with services based on type of difficulties and the age of the child, with parental programs being highlighted as a central part of intervention. Routines regarding the amount and type of treatment varied, where some SLPs had ‘precisely defined how many new visits and how many return visits I have for each diagnosis’ (Chaterine) and some ‘don’t experience that we really need to say no to return visits or that we can’t offer treatment and so on, but we are pretty structured regarding how much and how many times you can come’ (Amanda). There was a slight resignation regarding children who had greater difficulties and needed more extensive intervention. Some of the SLPs implied that this was a group that did not receive enough intervention because of regulations from the clinic. In addition, structures in the healthcare system, for example regarding assessment from psychologists, also had an impact. Multilingual children were also described as sometimes disfavoured by clinical routines:

We try to offer the same things to those who are multilingual and monolingual. However, we can see that the result will still be that they are offered AKKtiv and signs and then when they turn 4, they can be offered treatment and then we have a telephone interpreter. But we feel that they have a harder time to take it in still, and often decline treatment with us, from our experience. But that’s what we offer. (Lucy)

Zoe and Ruby, the two SLPs who worked in schools, described that their main commission was to help the children pass school and reach the goals set by the curriculum. The possibility to offer more traditional SLP services was described as limited, which occasionally evoked frustration:

If they then come to school and there are no SLPs who can work with direct treatment either, then there’s nothing. That’s absolutely crazy. I get a little jealous, just like […] to be able to offer treatment and, like, both pronunciation, but also on other levels, like it’s extremely frustrating. (Ruby)

However, being situated in (pre)schools was also described as highly beneficial when it came to getting access to the child’s everyday language and communication skills. Another advantage that was brought up was time. Whereas practicing within a clinic was stated as working under time pressure, and an ‘in - assess - out’-approach (Zoe), working at a (pre)school might entail ‘hang out with a child for two hours, and just listen and ask control questions. Let’s play.’ (Emma). As a result of the different frameworks, being stationed at a (pre)school was described as acquiring somewhat different working methods and approaches compared to the more traditional SLP services at a clinic. While practices at the clinic included formal assessments, working at a (pre)school required to ‘practice my ability to prick up my ears in these everyday situations to pick up language difficulties’ (Emma).

The type of employment was also said to influence the cooperation with the child’s social network:

I, I think back to when I worked at the clinic, that there you always had the parents present, and the connection with the family was very natural there. […] whereas here at the school where I am now, there is more of a connection to everyday life at school, and there you don’t have the parents present. But on the other hand, here you have like the children’s whole daily life. (Zoe)

The SLPs’ employment was expressed to provide the possibility to have a close collaboration with either caregivers or teachers, but rarely both. This was described as a disadvantage for both settings, where SLPs who worked in a clinic, and SLPs who were stationed in a (pre)school expressed a feeling of missing one part in the cooperation.

Result summary

In sum, everyday life was stressed as the ultimate target of intervention as well as the primary arena of language stimulation for children with DLD. However, the SLPs experienced themselves as detached from the child’s everyday context, and often struggled with setting intervention goals that targeted everyday abilities and needs. SLP clinics were not perceived to offer a natural context for children, and how the child performed in the clinic did not always reflect how (s)he functioned in everyday life. Cooperation with and information from caregivers and (pre)school staff were described as essential, but the SLPs often experienced a gap between different stakeholders, and overcoming that gap was a challenge. Currently, more children and their families are situated in multifaceted contexts (e.g. multilingually and/or socioeconomically) and need more extensive care than has previously been the case. The services the SLPs could offer varied and was to a large extent regulated by the routines of the employer.

Discussion

The present study adopted a qualitative approach, using focus groups to explore Swedish SLPs’ views of the alignment between their clinical practices and the everyday language and communication skills of children with DLD. The study aimed to further understand Swedish SLPs’ prospects for, and difficulties in delivering ecologically valid services to the target group.

The importance of, but also challenges associated with managing to target everyday life were stressed by the SLPs partaking in this study. For children with DLD, the language problems affect everyday life in different ways. Some children experience great disabilities whereas others hardly experience any language-related obstacles at all [8]. Hence, to adopt a broad approach in assessment and to include extensive information regarding everyday life functioning is essential. Swedish SLPs are often situated in an SLP clinic and make observations of the child mainly at the clinic. The SLPs acknowledged that this might not offer a complete picture of the child. Cooperation with, and information from caregivers and (pre)school staff are therefore essential to ensure alignment with, and relevance for the everyday life of children with DLD. The importance of collaboration with a range of stakeholders surrounding the child is widely recognised, and emphasised in previous research [e.g. 12,13]. However, the SLPs in the current study often experienced a gap with caregivers as well as (pre)school staff and expressed that overcoming this gap was a challenge. This is problematic, given the fact that Swedish SLP practices for children with DLD largely rely on information from, and participation of, people in the child’s network. In previous research, SLPs and teachers have been shown to hold different perspectives on DLD, including different conceptualisations and terminology, as well as approaches to assessment and intervention [21,22]. These differences in perspectives were evident in SLPs’ discussions in the current study, where the extent and quality of cooperation with (pre)school staff were described to vary greatly. There was even a suggestion that a mediator might be needed to facilitate communication between SLPs at the clinic and (pre)school staff. Difficulties in understanding each other and getting important messages across professional boundaries may inevitably have negative consequences on aspects of collaboration. Swedish SLPs situated at hospital clinics have a limited amount of time for each patient, and handover meetings with (pre)school staff are often conducted over the phone at singular occasions. If information is not received, or understood, the way it is intended, this may result in a lot less effective care for the individual child.

Additionally, the collaboration with caretakers was also sometimes described as a challenge, a matter that has been acknowledged in previous studies as well [e.g. 17,19]. The SLPs expressed that there is currently a growing group of children and families who live in multifaceted linguistic and cultural contexts, who are in need of more extensive care. In order to participate in clinical decision-making, caregivers must be well informed and supported [13]. However, to fully live up to the caregivers’ needs and prerequisites was highlighted as a great challenge, as was feeling sure that the information provided by caregivers were really accurate at all times. Caregivers and (pre)school staff are the main sources of information regarding children’s everyday abilities and needs for SLPs situated in clinics. When those sources are not reliable in providing sufficient or accurate information, the intervention will most certainly be adversely affected. It is important that SLPs have a variety of tools to ensure a productive collaboration with caregivers, with a shared view of the child and of the intervention. SLPs and caregivers might hold different perspectives on the child’s abilities or what is important, and determining the correct view is not self-evident. Caregivers are often uncertain about their capability and contribution in SLP intervention, and to empower caregivers has been stressed as essential for a successful collaboration [14,15]. Furthermore, to individualise intervention, it is crucial to recognise caregivers’ knowledge regarding their children’s strength and the difficulties they encounter in everyday life [23].

Despite the fact that there seems to be a large group of families in need of more extensive, individualised, and hands-on coaching in the Swedish SLP caseload, the SLPs describe a formalised way of offering services to children with DLD that to a high degree depends on the organisation in which they are employed. There appears to be few SLPs who have the opportunity to be flexible to a great extent to truly meet the sometimes complex needs of the children with DLD and their families. This is in line with previous research that suggests that organisational constrains decide how practices are structured, which has a negative effect on the possibility to individualise care [28]. Formalised and pre-structured services may suit many of the clients but will inevitably not benefit all. There is great diversity within the group of children and families seeking SLP care. Services must be linguistically and culturally adapted to ensure effectiveness for the individual child and their family [11], and individualised coaching is essential for empowering caregivers into being effective collaborative partners [15]. To enable SLPs to deliver high-quality care for children with DLD, it is crucial that they have the time and resources to customise services to each individual child and family.

Conclusions

The findings of the present study suggest that Swedish SLP services’ alignment to children’s everyday life is dependent on the abilities of caregivers and (pre)school staff, and by organisational constraints. There is great diversity within the group of children and families seeking SLP services, and individualised care is critical for targeting skills of relevance for the child, and for empowering their caregivers. Caregivers are often the main collaborative partners within Swedish SLP services for children with DLD, and it is essential that the SLP has the time as well as the resources, to ensure a supportive and well-functioning cooperation.

Limitations

All SLPs who participated in the present study had previously filled out a questionnaire regarding the alignment between SLP services and everyday abilities for children with DLD [38]. This method of recruitment may have affected which SLPs participated, attracting those with a pre-existing interest in the subject. In the focus group discussions, all participants expressed concern and had reflections about the matter. Some even brought issues they wanted to discuss in the group. Having previously filled out the questionnaire also guided the discussions to some extent, both consciously and unconsciously. On some occasions, the questionnaire was referred to by the participants. To further explore the subject, more in-depth interviews could be conducted with a wider range of SLPs. For example, including an entire workplace could potentially broaden participation and incorporate a more diverse range of perspectives on the matter.

The discussions were carried out on Zoom which possibly enabled more SLPs to participate, since it did not require time for travel. It also allowed for a mix within each group in terms of geographical affiliation. However, this might also have affected which SLPs who chose to participate, favouring those used to utilising the program and interacting online.

Ethical approval

This study was approved by the Swedish Ethical Review Authority [Etikprövningsmyndigheten].

Disclosure statement

The authors report there are no competing interests to declare.

Additional information

Funding

This study was supported by Majblommans Riksförbund; Stiftelsen Sunnerdahls Handikappfond.