ACQ Vol 10 No 3 2008

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ACQuiring knowledge in speech , language and hearing, Volume 10, Number 3 2008 93
INTERVENTION: WHY DOES IT WORK AND HOW DO WE KNOW?
2 Truth (we tell the truth). What evidence exists regarding
the effectiveness of our interventions and what do we
discuss with our clients? How do we find information
about best practice recommendations?
3 Fairness (we seek to ensure justice and equity for clients,
colleagues and others). If we know the evidence for some
interventions is better than others, do we advocate this for
all clients equally? Do we consider external factors such as
financial hardship when discussing options with clients?
4 Autonomy (we respect the rights of clients to self-
determination and autonomy). Despite our own opinions,
do we provide our clients with enough information about
alternative interventions and service delivery options so
they can make their own informed decisions?
5 Professional integrity (we demonstrate professional
integrity as people would expect). When we present
information about different interventions do we do so in
an unbiased way and clearly state what our own stake in
the choices might be?
Within the scope of this column, it is impossible to answer
all of the ethical questions posed above. However, it is
important to address the key issue here – that of evidence
based practice (EBP). EBP is not just the latest fad; it’s been
around too long to be considered that! EBP requires us to
integrate all of our clinical experience and expertise with the
latest well-conducted research so as to understand whether
what we do works. We also have to consider the context for
both the family and service provider (which may include
finances and geography through to age and motivation).
In order to address Geraldine’s question, the speech
pathologist must integrate the results of systematic and peer-
reviewed research on language interventions for school-aged
children with his/her own experiences in clinical practice.
Excellent resources to do this include (but are not limited to):
the Cochrane Collaboration ),
Evidence Based Practice in Speech Pathology (Reilly, Douglas &
Oates, 2004), the new SpeechBITE™ initiative from Speech
Pathology Australia and the University of Sydney (http://
It is important to balance clinical expertise with the
necessity for evidence from systematic clinical trials of
interventions. For example, a randomised control trial re­
cently published by Gillam et al. (2008) draws some important
conclusions about different treatment conditions (e.g.,
computer-assisted language intervention and individualized
language intervention) and the variety of activities that can
facilitate development. In a recent ASHA forum, Hoffman
(2008), a practising speech pathologist and researcher,
reflected on her experience of participating in this large
clinical trial:
For every child who ate a particular type of treatment
up with a proverbial spoon, there was one for whom
that treatment was as appealing as dry toast. It was then
that I truly understood the necessity of large scale trials
… I could see that clinical expertise is built on individual
results, it very clearly shows the trees, but across a large
scale that particular compass can’t guide one out of the
forest very well.
With the best available evidence on intervention outcomes,
a conversation between Geraldine and the speech pathologist
can begin to consider:
• the available evidence for each intervention type;
• what improvements Julie might be expected to make;
Evidence base for the treatment
The “new” treatment may not have a strong evidence base. If
I know little about the treatment I cannot support nor deny it.
I need to provide Geraldine with the information and the
means to analyse and understand the treatment. I may assist
with identifying questions Geraldine could pose to those
promoting the “new” treatment and provide Geraldine with a
background regarding the standard, accepted current
treatment methods in this area and why they are accepted.
I often speak in generic terms with parents and carers about
non-mainstream treatments and the pitfalls of some of these.
Parents and carers are alerted to and can be mindful of the
pitfalls when making their decision as to whether or not to
support a new treatment. It is important to preface any
discussion regarding a treatment with an honest disclosure of
any bias I may have in relation to a treatment’s validity. This
discussion and assessment of validity will (hopefully!) be
based on the presence or absence of accepted research and
evidence. A discussion may also be required on the unknown
and unclear outcomes of treatment techniques that lack
research and/or are poorly researched. It is important to keep
in mind that both accepted and unaccepted treatments are
often poorly researched.
Lack of knowledge/professional learning
If I do not know about the “new” treatment, it may be time to
investigate and learn more: literature searches, discussion
with peers, contacting the service myself. I have a
responsibility to know about such treatments, provide
guiding information, know if I am discussing a treatment that
may do harm. However, in the prioritisation of time, not all
new “fads” can be investigated and I need to make decisions
regarding their importance before investing significant time
in researching their validity.
Professional role
I feel trusted by Geraldine as she is asking my opinion about
this “new” treatment. I need to make it clear that this difficult
decision is hers and I will respect the decision she makes,
whatever my bias. My role is to provide information em­
powering her to make a decision. The persuasive power of
the “expert” role is a force I am always aware of and aim to
limit as much as possible. This scenario has the potential for
me to take the “expert” role rather than one that empowers
parents/carers to assess the program themselves.
Parents often seek “expert” advice, which is not a bad
thing. However, it is important to present the information in
such a way that parents/carers can still make informed
decisions. Using statements such as “my assessment of this
is…”, “this could mean…”, “the risks may be….”, and “the
benefits seem to be …”. In the end parents and carers may
make a decision against my advice, yet my aim should always
be to respect their decision. Arming our clients with the tools
that facilitate autonomous decision-making (“Autonomy”,
Principle 4 of our Code of Ethics; Speech Pathology Australia,
2000) is the key.
Response from Dr Patricia Eadie, Speech
Pathology Australia Ethics Board member
This scenario generates questions around each of the five
principles that form our Association’s Code of Ethics (2000).
1 Beneficence (we bring about good) and non-maleficence (we
prevent harm). Is there evidence that different inter­
ventions improve the well-being of our clients and to the
same degree, or do some potentially do harm?