Dr. Tanuja Gandhi (Host 1): Welcome to Mindcast, a podcast from the experts at Bradley Hospital, the nation's first pediatric psychiatric hospital. I'm Dr. Tanuja Gandhi, your co-host.

Dr. Greg Fritz (Host 2): Hello, everyone. I'm Dr. Greg Fritz, your other co-host. And today, we're talking about speech therapy. Speech therapy has evolved so much in the last decade. Here with us to discuss speech and the intersection of speech therapy and mental health is Rebecca Craine, a speech pathologist at Bradley Hospital. Welcome, Rebecca.

Rebecca Craine: Hello, thanks for having me. I'm really excited to be here today to talk a little bit about speech therapy and mental health.

Host 1: We're so glad to have you. Certainly, we've seen an increased need for speech therapy in our schools. And when we were talking about it a few weeks ago, you had mentioned the unique ways in which speech therapy can help some of the patients with mental health challenges. So, can you first help us understand and establish who is a speech-language pathologist?

Rebecca Craine: Of course. So, a speech-language pathologist, also known as speech therapist, assesses and treats people with a variety of speech, language, voice, fluency, and swallowing disorders. Speech pathologists work across many settings, including schools, acute care hospitals, home care, outpatient clinics, and universities.

 Through our education in speech pathology, we're able to work across the lifespan, so we are able to diagnose and treat a variety of disorders. Many times, we work alongside a great treatment team of individuals, so this could be doctors, nurses, teachers, it really goes on and on. So, when I worked in the school-based setting, I worked with the teachers to establish IEPs for kids, behavior plans, and then I work in acute care settings where I'm working more on swallowing and cognition. So, it's a really big variety. Commonly, people believe speech therapists only treat, you know, little kids with articulation disorders, like their R's and their S's, but there's a real lot more that we cover in our profession.

Host 2: So, one of the most interesting things to me is what's happened since the COVID pandemic, and that there's a lot of research showing that there's been dramatic increase in the number of young children who are slow to develop their language skills and showing with pediatric speech delays, more than actually doubling, there's more than twice as many of them now as there were before the pandemic. Help us understand that. That's a remarkable difference.

Rebecca Craine: Yeah. It's been a large difference from before, and we're still trying to play catch-up, even four years later. And a lot of it had to do with when the shutdown occurred, students were already receiving services stopped getting services. Children who were eligible for early intervention were eligible, but there was nobody to treat them. So, a lot was happening virtually. And if you think of a two or three-year-old, they're not really too able to participate in virtual treatment for speech. So, that service was delayed. Also with the shutdown, people weren't going to daycares or schools. They were home with their families. So, there wasn't as much social communication that children are used to too. And a lot of language development is through exposure. And there was not a lot of exposure during that time. So, we're really playing catch-up with these children who didn't receive services when they should have during the pandemic.

Host 2: So, they didn't receive evaluations and maybe the problems weren't recognized. And even when they did know that they had problems, they couldn't get the help that they needed and all that backed up.

Rebecca Craine: Yeah.

Host 2: Wow.

Rebecca Craine: We're still seeing it now. So, the kids who went back to school after COVID, we were saying, "Okay, we need to evaluate them." But now, there's also the kids coming in that kindergarten year too. So, we kind of doubled up on all of the evaluations and treatment that needed to be completed. Overwhelming for them and for us at times.

Host 2: Yeah.

Host 1: So, once a child is school aged, you know, many schools have screenings to make sure they're hitting their milestones and basically on track with development. Can you help us understand how are schools identifying the need for speech therapy and what does this process look like?

Rebecca Craine: So, for kids who have received early intervention, it's a little easier. The child will go through a re-evaluation process at the end of early intervention through the school district, so they're able to be picked up in that preschool year. Some preschools or daycares also do screenings during that time that can pick up on these needs for these children, but it's also really important that the PCPs are the ones that are seeing these screenings and asking parents questions, because then the PCPs can also make referrals over to outpatient or school-based teams for further evaluation. But usually, if a child is in school already, teachers or even caregivers can reach out to the special education director, whoever at the school is in charge of that, to have the school really look at the child a little deeper to see what additional services or evaluations they may need.

Host 2: So, what are the consequences of having speech disorder and having it be untreated? is that something kids just grow out of and we'd like to dream on?

Rebecca Craine: I wish that was the case, then I'd be out of a job, really. So, there are a lot of consequences of a child kind of going untreated for certain areas of speech and language. You know, we could have a 16, 17-year-old going back to the R's and S's who is still not saying their R's, which can make them sound a little bit more immature for their age. People might not take them as seriously when they're speaking. That's a consequence right there. But if we think of language and how children develop language over time, if they're not getting the basic concepts as they grow older in academics or just in social communication, those deficits are just going to keep piling up. So if they're unable to recognize social cues at a young age, and they grow up continuing to not know those social cues, they're going to have a lot of trouble making friends, or formulating relationships, or being able to interview for a job. So, they really do pile up.

Another thing with children with language deficits, it really impacts their academics. Think of, there is language involved in mathematics if you think of word problems, those basic concept words. Language is all around us, so if it's not treated, it can lead to further difficulties for the child.

Host 2: So, parents are a big part of every child's environment and have so much interaction with them. How do speech pathologists work with the parents and are there any kind of barriers that get in the way of working with parents or families?

Rebecca Craine: So, depending on where the child is receiving the services, if they're receiving the services in home or in an outpatient clinic, a lot of the times the speech pathologist will do one-on-one training with the parents at the end of the session or include them in the sessions so the parents are aware of what strategies are useful or what the child benefits from.

When a child is receiving speech therapy in a school-based setting, a lot of the education is done to the teachers and other staff that are working with the child, and the parents don't get the education as frequently unless they're attending a meeting or there's information sent home. I always say it's important for parents to reach out whenever they feel they need more support to the speech pathologist, especially in a school setting, because you don't have that constant communication. And just asking, "Hey, what's working for them? What can I do at home?" We're always willing to give any kind of education to caregivers or parents.

And then, if a parent feels like their child is not receiving enough support, whether it's at school or an outpatient, there's always alternatives to look for. There's always additional therapies that you can reach out to. I know children receive social communication therapy at school. It's usually in individual or in a small group, but there's a lot of places out in the community that do big social skills training. They'll bring the kids out together with same-age peers. So, there's always other options sold for if parents don't feel like they're getting enough.

Host 2: Oh, that's great. Very useful.

Host 1: And I think it's important to identify that a child's behavior is also a form of communication. I wonder if there are a few things that you could help the parents listening to this podcast know about that they could pick up in the home if there's a need for speech therapy and identify that need.

Rebecca Craine: I feel that this is for children across the board, even if they do not have a specific psychiatric diagnosis or a speech and language diagnosis. I think these strategies are great for all children, because behaviors typically occur when a child is unable to formulate their language to express their feelings or their needs or when they're unable to recognize those body signals that we know as adults to say, "Something's not right and this is what I need." So, we see more behaviors.

I wrote this down so I didn't want to forget it. There's an organization called Learning for Justice, and they created the acronym EATS looking at possible functions of a behavior. So, E stands for escape. Does the child want to escape the situation? A is for attention. Are they trying to obtain attention? T is for tangible gains. Do they want food? Do they want an object or a toy? And then, S stands for sensory needs. And this is why it's important to work in that multidisciplinary team that a child might need sensory things, and we'll go through occupational therapy to get those.

But I think that's really important for these kids to say, "Okay, I need to escape this situation. How can we support that child in now learning how to communicate when they need to escape?" So, some simple strategies I always recommend are labeling the child's feelings. "Oh, you look really frustrated, or that looked really scary for you." A lot of the times the children don't have the language to label their emotions. Assist them in identifying the cause of their behavior. "Okay, I could tell you were frustrated and you didn't want to do this anymore. You wanted to leave the situation." Model appropriate language for them. "So, next time you have this feeling, you can tell me, 'I'm frustrated, I need to take space.'" And then, you can also provide choices. "I saw you were frustrated in that. Do you want A or B?" And offering them choices.

In a case where this is a reoccurring problem for a child and they don't seem to benefit from those other strategies, as a speech pathologist, we will usually create social stories or do some role playing situations with the child so we can really put that child in the context that they have the trouble and then walk them through the appropriate steps. And the more the child sees these steps, the more they become familiar with how it should look like rather than using those behaviors.

Host 2: So, can you tell us about any obvious connections that you can identify right away for speech and mental health concerns in kids where they go together and resonate off one another?

Rebecca Craine: Yeah. So, there's been a lot more recent research, which is great. About 71% of children with an underlying mental health disorder have a comorbid speech and language disorder, and 71% is pretty high if we think about it. There's lots of specific disorder areas that have more general characteristics that we see, ADHD versus like a schizophrenia. So, a lot of commonalities we see are difficulty with social language. So, are they making appropriate relationships with others? Are they able to initiate and respond to bids for interaction with adults and peers? Are they able to formulate sentences so that they make sense? Attention has a large piece to do with language as well. So if you think of our children with anxiety, depression, ADHD, because they're in a hyperarousal state or hypoarousal state, they're not processing their environment, so they need more supports understanding language and expressing themselves.

We've been seeing a lot more need for children on our units for transitions. Transitions are really hard for our kids. Any sort of change in the language around that change, and we're seeing that these supports that we're providing to them that are language-based are actually helping them succeed.

Host 1: So, it seems like we have a lot of ideas on what to do if you identify speech deficits or a need for speech therapy at home or in school. This has been such an illuminating conversation. Thank you for joining us today.

Rebecca Craine: Of course. Thanks for having me.

Host 1: And also, thank you for listening. Our podcast is available on Spotify, Apple, and YouTube, and all other major podcast players. If you enjoyed this podcast, please share it with your friends at bradleyhospital.com/podcast. And until next time, thank you.