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Four-year-old Eddie Hopkins is focused on a game of I spy. The object of his attention is a tube of lipstick in a picture.
Can he say what it is?
“Lipstick,” he says, but it sounds more like “lit-git.”
Maybe lipstick is too hard. Can he say stick?
“Sti-ck,” he says, hesitating before the k sound.
One more try.
“Sti-ick!” he shouts confidently, dividing the word into two.
It seems like a small accomplishment, but for Eddie, it’s the first and major step toward speaking normally.
Like tens of thousands of children in Ontario, Eddie is in need of speech therapy. He has problems pronouncing the hard k sound, known as an unvoiced velar stop. He often switches it with the voiced velar stop, which most people know as the soft g sound, bringing him from “stick” to “stig.” He also switches his sh and s sounds, and has issues with pronouncing two consonants together, such as the “cl” in “clown.”
Eddie gets his speech therapy at Toronto’s Canoe Therapy, a clinic in Etobicoke. Each session costs about $130 and is covered by his mother’s health plan.
For many other children who aren’t covered by health plans, the only option is to go through the publicly funded speech-therapy system. Children of school age can get therapy either through speech pathologists in school boards or through Community Access Care Centres in Ontario (or similar community-care agencies in other provinces), depending on the type of speech problem.
But the wait lists for in-school speech therapy can be exorbitantly long, leaving children without care for months, or even years. When the children do get therapy, it’s only within a finite amount of sessions, which are often not enough to treat the child completely. It has many in the field calling for an overhaul of a fragmented system that is slow to respond to children looking for care during a critical time in their development.
In Ontario, if a child needs speech therapy, they first get assessed by a speech pathologist. If they’re of school age, they are divided into two categories. Those with language concerns – that means major problems speaking, go to their school board’s speech pathologist.
That leaves a large portion of Ontario children whose problems don’t qualify as language concerns. These children, whose problems include stuttering, articulation, voice and fluency, get referred to the Community Care Access Centre (CCAC) in their region. Depending on which CCAC region they live in, their wait time can range from non-existent to two years.
The average number of people on wait lists as of May, 2015, is 611. Some regions have shorter wait lists, such as Toronto Central, which currently has zero. Others are in the four digits, such as the Central East CCAC, which stretches east from Victoria Park Avenue in Scarborough and north to Algonquin Park, and has 1,516 children waiting for speech therapy.
Waiting that long can have a large impact on a child’s ability to do well in school, according to Anila Punnoose, a director of Speech-Language and Audiology Canada. During the months or years children are waiting to get speech services, they can quickly fall behind in school, she said. A 1996 study found children with language deficits are more likely to experience social difficulties including interacting with their peers, which impacts their behaviour. Other studies have shown that children who don’t get speech therapy early are at a greater risk of problems in their academic performance and mental health.
A lot of speech problems carry over to literacy, because a knowledge of speech sounds is crucial when learning to read, Punnoose said.
“It’s all about what you hear in those sounds. … Do you know the beginning sounds in that word? A child who doesn’t have good phonological awareness doesn’t understand any of that,” she said.
When looking at school performance, Punnoose said early struggles carry through to later years. A child with speech problems who has difficulties learning in the early years won’t be able to build on those lessons in later years as effectively as their peers, she said. Early intervention can mitigate and prevent those problems, she said.
“If children are having severe difficulties with speech in kindergarten, it’s a predictor that there’s going to be academic difficulties, and especially reading and writing difficulties, by Grade 3,” she said.
Jocelyn Fedyczko, Eddie’s speech pathologist, has worked in a range that includes children from preschool all the way to teenagers. She said early intervention is crucial with young children such as Eddie.
“The earlier you can help a child out, the more progress you see,” she said.
When a child gets to the top of the wait list, they get assessed again, and receive a block of treatment, usually around 10 or 12 sessions, says to Peggy Allen, president of the Ontario Association of Speech-Language Pathologists and Audiologists (OSLA).
That’s often not enough to treat even minor to moderate issues such as Eddie’s. Fedyczko said she can get through two to three sounds in that time, depending on the child. Many children have problems with more sounds than that, she said.
But when a child finishes their block of treatment and needs more, because they haven’t worked through all the sounds, for example, they go back to the bottom of the wait list, Allen said.
A spokesperson for the Toronto Central CCAC said they do not have an upper limit to the number of sessions per block assigned by a speech-language pathologist. The pathologist determines three goals for a child to achieve and assigns the number of sessions according to that. If after these sessions more goals are identified, the child is re-referred to the program, the spokesperson said.
Parents who are worried about the impact waiting can have on their child can go to private clinics, if they have coverage or can afford the sessions out of pocket. Trish Bentley, Eddie’s mother, decided to go for private therapy with Eddie’s older brother Oliver.
He was put on a six-month wait list for speech problems slightly more acute than Eddie’s. Rather than wait those six months, Bentley took him to Canoe.
“As time went on, we said enough of this, he’s going to be past the point of catching the problem,” she said.
For families who don’t have coverage and who can’t afford private services, though, the only option is to wait.
Finding the cause of the long waits is hard, but one thing is certain: It’s not due to a lack of speech pathologists, according to Shanda Hunter-Trottier, the owner of S.L. Hunter Speechworks, another private clinic in Toronto. She used to have problems finding qualified speech pathologists, but now she’s facing the opposite problem.
“I’ve been practising for 26 years. … In the last five years, [I] have more résumés than I can keep track of,” she said.
Rather, she says, it’s a large web of problems that slows down the system. First among these is a lack of public funding.
“There’s a lot of speech pathologists that don’t have jobs, but these places aren’t hiring. The cutbacks have been atrocious,” she said.
But the problems go deeper than a lack of funding, according to Allen. She said many of the issues in Ontario stem back to a series of agreements in the 1980s between the provincial Ministry of Long-Term Care, the Ministry of Education and the Ministry of Community and Social Services. These agreements divided up who is in charge of different treatments, between the school boards and the CCACs. At the time of their creation, these agreements made sense, but times and needs have changed, she said.
“It’s difficult when ministries make agreements that are frozen in time. It’s very difficult to provide the kind of services that we all expect and want Ontarians to receive,” she said.
Dividing up the services is necessary when trying to manage resources, but the fragmentation is hurting children more than it’s helping, Punnoose said. Dividing services by language issues and other issues doesn’t make sense when treating a child, she said.
“You shouldn’t be splitting up the kid,” she said.
Punnoose said she wants to see speech therapy come together under one roof. It would mean co-operation from all three ministries, as well as a major reorganization of the funding, but she believes it would be a better model for children.
“Students are in schools the better waking part of their lives. Why wouldn’t we have the services right there in an authentic environment where it’s totally accessible,” she said.
There are changes coming. Last December, the Ontario government announced more funding for preschool speech and language programs, as well as efforts to integrate speech services better, through its Special Needs Strategy.
Punnoose says it’s a good step.
“The government recognizes that the system was broken,” she said.
For now, the choice for parents in many CCACs will be between long wait lists and paying for private service. Hunter-Trottier said many parents, even those with coverage, don’t know about the latter option.
“We sometimes get parents here in tears, saying, ‘Oh my goodness, the services here, I wish I had known about that a year ago,’” she said.
Trish Bentley said she won’t be looking at public services for Eddie, as she’s happy with the service she gets at Canoe.
“I’d be open to it, but I’m not going to actively seek that out,” she said.
For Eddie, what matters is the progress he makes.
Within 10 minutes of his trouble saying “lipstick,” he was opening up a treasure chest, with a key. With little prompting, he used the same technique as before, separating the sounds of the word.
“Kuh-ey,” he said. Could he try it all together?
He pauses for a second.
“Key,” he says, almost flawlessly, beaming at his success.
Speech therapy, like all health-care matters, is regulated differently in each province and territory in Canada.
Information on how each system works is difficult to come by. But generally, most provinces have very similar systems – and challenges – according to Joanne Charlebois, CEO of Speech-Language and Audiology Canada. Charlebois said Ontario’s wait times are probably worse than those in other provinces, but she’s spoken to people across Canada who tell her similar stories.
Here’s a breakdown of how it works across the country.
Ontario: Speech therapy for children falls under the responsibility of three ministries: the Ministry of Long-Term Care, the Ministry of Education and the Ministry of Community and Social Services. Children in Ontario are divided by age and by the nature of their speech problem. Children under school age qualify for Ontario’s preschool speech and language program. Once in school, those children with language problems – major problems speaking or understanding words or sentences – go to a school speech pathologist, while any other problems, such as pronunciation, stuttering, voice and articulation are referred to the Community Care Access Centres, which employ contract speech pathologists.
B.C.: Children’s speech therapy is organized through the Ministry of Health, Ministry of Children and Family Development (MCFD) and through the Ministry of Education by way of school districts. Children are divided between preschool and school age. Preschool children go through regional health authorities. School-age children go through the school boards, but the pathologists there will often offer consultative services, rather than one-on-one speech therapy. B.C. also has a “no-wait-list” policy for children with autism, which translates to parents getting around $22,000 a year for therapy until the age of six, and $6,000 a year after that.
Alberta: Health Services is in charge of speech therapy in that province. It offers both a preschool and a school program. The school program, unlike Ontario’s, is done completely through the schools, with no CCAC-type system to refer out to.
Saskatchewan: The school districts are responsible for speech therapy. Each school district divides up services slightly differently, though they all differentiate between children under three years, from three to five years, and from six to 18 years.
Manitoba: School districts are also in charge here. The in-school speech-language pathologists offer services from classroom-based programming to individual therapy.
Quebec: The system here is more like Ontario’s. Speech-therapy services are offered through the local community service centres (CLSC), similar to Ontario’s CCACs. The CLSCs are not obliged to provide speech therapy in English, though some, especially in areas with a large anglophone population, usually do.
Nova Scotia: The province has 28 speech and hearing centres, with 35 pathologists in total. They assess and provide treatment for children and adults. School boards in the province also have speech-language pathologists who also have a teacher’s certificate.
Prince Edward Island: The province provides free speech services for children until they enter school.
Northwest Territories: Speech therapists are only able to visit some remote communities once or twice a year. Instead, the province offers a service called Telespeech, where pathologists can help people without having to be physically present.
Nunavut: The territory had no speech pathologists in 2013, according to Statistics Canada.
– Oliver Sachgau