Hospitals tend to offer services that are more diagnostic in nature for pediatric speech-language pathology. For evaluations, hospitals can provide excellent services. Many times, speech and language evaluations in this setting are offered as part of a team-based approach. Professionals from several different disciplines (e.g., developmental medicine, neurology) coordinate multidisciplinary evaluations that can zoom out for a big picture perspective of your child, that goes beyond the areas of just speech language. Integration of results from a group of professions is valuable for getting a holistic view of your child’s needs and it is helpful to better understanding your child's specific strengths and weaknesses, and for setting priorities, especially when there are many areas to address in intervention. In New England, there are several exceptional hospitals that have reputations and proven track records for being able to provide these types of multidisciplinary diagnostic teams and evaluations ( e.g., Boston Children’s Hospital, MGH).

On the flip side, hospitals do not often offer high volume on-going intervention. Short-term intervention is often offered in hospital settings more as a temporary “bridge” until a family can find an outpatient setting for continued care.

School-based speech therapy is the most common type of pediatric speech therapy.   

These services are typically provided to meet a federally mandated requirement through an individualized education program (IEP). Eligibility, its purpose, and service delivery logistics are driven by these requirements and the policies and constraints of each individual school district.   

Eligibility  
Children are typically eligible for school-based services from ages 3-21.  These services are often available even if your child attends private school.  Eligibility is often based on district-specific cut off test scores and the professional opinion that deficits in speech and language skills are negatively impacting a child in a way that is relevant to the school setting, academically or socially.  

Not all children who have a speech and language need are eligible for speech therapy at school.  If your child’s speech and/or language disorder does not impact them academically, your child may not be able to receive services.  Eligibility decisions should not be confused with need though.  Just because the school your child attends does not initiate an IEP, it does not mean that your child does not need speech and language therapy.  It just may mean that the services do not need to be offered through your town or city through this program.    

Purpose  
In the early years, preschool to early elementary school, the priorities of school-based services align more closely with developmental expectations.  This is because the work of learning during the very early parts of school-based experiences is all about gaining foundational skills.  This includes learning speech and language skills.  

During the majority of elementary school years, focus shifts from building the basics to building on foundational skills to learn new content.  At this point, school-based therapy prioritizes support of a child’s ability to meet grade-level requirements.   Therefore, priorities are placed on language (how we understand or express a message) over speech (how sounds are produced) in many cases.   Persistent difficulties at this stage often need more support than is fitting for a school district to provide. 

Service Delivery  
The implementation of school-based therapy is constrained by logistics of time, space, and resources. 

Within an individual school, a school-based SLP must balance the needs of an entire caseload of children within the hours of a school day.  Speech and language therapy is offered as a special education service either in or out of the classroom, either 1:1 or in a group.  Group services are very common in order to meet unreasonably high demand. In school districts with large student populations who have eligible speech and language needs, SLPs are tasked with providing intervention within the constraints of a school day, minus regular or special education instruction, art class, music, gym, recess, lunch, school-wide assemblies, and special events, like picture day, field day, and field trips.   

School-based speech therapists are often providing intervention within the classroom or in alternative spaces.  While there are some benefits to working within a child’s natural context, regularly treating in the back of classrooms, hallways, or in tiny rooms that are shared, contributes to limited opportunities to engage each student with individualized attention and support with intensity.    Having met with hundreds of SLPs working within the school systems over nearly two decades, SLPs candidly share that they are put in the difficult position of having to think creatively about how to conduct therapy in school settings.  Many school-based SLPs we have met selflessly spend their own money to buy supplies and materials for their students.  Others have more appropriate available budgets.   
In short, in most schools a school speech therapist simply isn’t provided the tools and environment they need to truly help students succeed with their speech therapy goals.   

Several important notes about school-based SLPs 
First, as pediatric SLPs ourselves, we are continually in consultation with school-based therapists.  They are masters of our craft in less-than-ideal circumstances in many instances. They contribute a great deal to the work we do in providing expert insights into what happens with skills in real world, academic, and social applications.  They offer invaluable support to school-based staff including teachers, BCBAs and other professionals working with children who have speech and language needs and often advocate like no others to ensure that eligibility is granted to their students.  The harsh realities of the school-setting, though, are still a barrier to their ability to meet their students’ needs comprehensively.   In our experience, many school therapists make a herculean effort to do everything possible to help their students.   Their commitment and dedication are nothing short of remarkable.   It is extraordinary when you look at how much many school speech therapists are able to do within the framework they are required to work within.  It is very impressive to say the least. 


Second, we should also point out that there are some school/districts that outshine the average school.   They provide speech therapists the tools needed, low caseload size, and  appropriate time to dedicate to their students planning and treatment.   Those are just few and far between. 

Historically, home-based intervention was reserved for Early Intervention and freelance speech therapists, who work with a few clients by independent contract with a family.  In more recent times, home-based therapy has become very popular.  Why?  In part, people are busy.  Making time for a standing appointment for speech therapy can require quite a balancing act of extracurricular activities for a child with speech and language needs and competing schedules for the whole family!   Unfortunately, due to the high costs/overhead of having a medical space like a clinic, many speech therapists have turned to the model for pediatric speech therapy as well. Superficially, there are several appealing reasons why home-based therapy is attractive as a method for attending speech therapy but the limitations of this service delivery model have a direct impact on rates of progress. Therefore, pros and cons must be weighed carefully.  

Let’s start with the positives.  

Working in the “natural environment” has the benefit of being more convenient because a child and family can stay within the comforts of their home and still attend a therapy appointment.  Another advantage to home-based intervention is that target sounds and language forms can be mapped onto familiar toys, games, favorite stuffed animals and household items.  Household routines can also be observed by a home-based SLP to make recommendations of adaptations and to better understand the communication styles and demands in a child’s home setting.  Rich opportunities to engage with a participating parent are also easily realized when children receive speech and language therapy.   

Home-based intervention through Early Intervention ( for 0-3 years) can also be valuable and we regularly partner with home-based SLPs who work with our patients in coordinated care.  Home-based EI offers the opportunity to generalize skills and train parents using strategies and techniques in the home environment where the child is familiar and with loved ones.  For the birth-three age range, these services are often helpful to facilitate a child’s growth and development of early language learning by having parents actively engage in the therapy.  While parent participation and support is a valuable component of a child’s language learning experience, it does not fully address therapeutic needs for efficiently learning new skills.  Some children will benefit more from direct intervention that is overt and teaches specific forms in an intentional method where naturalistic learning did not increase speech or language use.     

For addressing new skill development for children who have struggled to develop speech and language skills, the environment matters.   Let’s talk about some of the drawbacks of the home environment for learning.    

If a home-environment was idealized, there are some benefits to being at home for speech and language therapy.  Who would not want to skip a commute to an office, getting in and out of the car, traffic, parking and the extra allotment of time it takes to leave home for therapy?   If enrolling in speech therapy at home was analogous to ordering a pizza and eating it at home versus at a restaurant, this logic may lead many families to stay at home for speech therapy services. However, in reality, the home-based model has some significant limitations.  We have heard from countless parents who have arrived at this conclusion on their own about hosting speech therapy at home, and at the end of the day, the lack of progress is at the core of the issues shared by many of our families.  

At home, life is happening.  What would otherwise reflect an active, happy home, is potentially counterproductive for a speech and language therapy session and to achieve maximal gains over time.  Home environments are a child’s home turf.  It can be distracting, chaotic, and is not usually set up for therapy.   Since speech therapy is largely focused on teaching new skills, the hustle and bustle of a home is not going to be the ideal setting for the fastest and most effective outcomes for the vast majority of children. In addition to those child focused factors, clinical supervision and clinical accountability is generally much greater in a managed environment as opposed to working alone in “peer isolation” at disparate homes throughout the day.    Clinicians are also able to prepare for a treatment session more thoroughly in a dedicated space as opposed to working with what’s available in someone’s home.   Available resources and materials also tend to be far more extensive in a clinic-based model. 

For home-based speech and language therapy, there is an inherent tradeoff between convenience and quality of intervention.   

Clinic-based private practice is really considered the gold standard for ongoing outpatient speech therapy services in our field.  The term “private practice” is used broadly to include therapists working for agencies who are outsourced to a school district.  This is functionally school-based therapy.   

Sometimes, private practice therapists work in homes; this is functionally home-based intervention.   For the purpose of this blog, let’s define private practice as being clinic-based, meaning therapy is taking place in a facility, and not a home or school. 

It is also worth noting that there is a wide range of approaches within the world of private practice speech therapy.   In fact, our approach is fairly unique in itself and not the traditional method of service delivery (read more about our speech therapy approach here).  

Regardless of the approach, though, having a dedicated space for a child to work 1:1 with a speech therapist will generally allow them to focus more and have better/faster outcomes.   It allows the speech therapist to prepare more for each session, it gives them better control over the level/types of scaffolding or support, engagement and motivation, and it increases the level of supervision and accountability.   Success rates are better and goals are often reached more quickly in a clinic with dedicated treatment rooms.   

This setting also allows for clinicians to consult with and work with other therapists or professionals, sharpening their skills.   Parent communication is regular and frequent.    
At the end of the day, this is a medical service, an important service, and we believe achieving a child’s speech-language goals as quickly as possible is critical to giving each child every advantage possible so the can meet their fullest potential and enjoy being a kid. 

Is there a downside to clinic-based intervention?     

Yes.  Enrolling in clinic-based services will take commitment to the process.   

We recognize that participation in clinic-based intervention takes a tremendous commitment on the part of dedicated parents to attend in at least weekly therapy, and regularly engage with therapists to learn more about speech and language development to best support their child at home, school and in the community.   It takes time, effort, resources, and putting communication goals before many other  activities and appointments.  We are continually impressed and in awe of the families we have the privilege of serving at the practice, who consistently commit to making speech and language development for their child an important priority.