In this Papers Podcast, Dr. Yvonne Wren and Dr. Emma Pagnamenta discuss their co-authored JCPP Advances paper ‘Social, emotional and behavioural difficulties associated with persistent speech disorder in children: a prospective population study’ (https://doi.org/10.1002/jcv2.12126).
There is an overview of the paper, methodology, key findings, and implications for practice.
Discussion points include:
- A definition of Persistent Speech Disorder.
- Why Emma and Yvonne chose to focus on Speech Sound Disorder in this research.
- What the four core questions are that drove the research.
- What was unique about how they went about the study.
- Insight into what the Strengths and Difficulties Questionnaire and the Short Moods and Feelings Questionnaire are and how they were used in the study.
- Advice for practitioners, and for parents and carers.
- The policy implications and what needs to change at policy level to see an improvement in outcomes for young people with persistent speech disorders.
In this series, we speak to authors of papers published in one of ACAMH’s three journals. These are The Journal of Child Psychology and Psychiatry (JCPP); The Child and Adolescent Mental Health (CAMH) journal; and JCPP Advances.
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Dr. Yvonne Wren is Director of Bristol Speech and Language Therapy Research Unit, based at Southmead Hospital and part of North Bristol NHS Trust, and is also Associate Professor of Speech and Communication at the University of Bristol and a Reader in Speech and Language Therapy at Cardiff Metropolitan University. Yvonne’s role across all three institutions is to lead research which has potential for impact in the fields of speech, language, and communication development and disorder across the lifespan. Yvonne’s research interests include speech development, disorder, cleft palate, speech and language therapy, communication impairment.
Dr. Emma Pagnamenta is a Speech and Language Therapy Lecturer and a practising Speech and Language Therapist at the University of Reading. Emma is co-lead of a research group called the Speech, Language, and Communication Developments Group and also co-lead for Health at the Centre for Literacy and Multilingualism at Reading. Emma is particularly interested in the outcomes of communication needs in childhood and also thinking about what we can do to support children that have these communication needs. Emma’s research interests include speech, language and communication disorders in childhood including speech sound disorder, developmental language disorder, learning disabilities and Down Syndrome.
- Featured paper ‘Social, emotional and behavioural difficulties associated with persistent speech disorder in children: A prospective population study’, (2023). Yvonne Wren, Emma Pagnamenta, Faith Orchard, Tim J. Peters, Alan Emond, Kate Northstone, Laura Louise Miller, Susan Roulstone
[00:00:00.099] Mark Tebbs: Hello, welcome to the Papers Podcast series for the Association for Child and Adolescent Mental Health, or ACAMH for short. I’m Mark Tebbs, Freelance Consultant, Leadership Coach and currently working as a Mental Health Commissioner. In this series, we speak to authors of papers published in one of ACAMH’s three journals. These are the Journal for Child Psychology and Psychiatry, commonly known as JCPP, and the Child and Adolescent Mental Health, known as CAMH, and JCPP Advances.
Today, I’m delighted to be interviewing Yvonne Wren of Bristol Speech and Language Therapy Research Unit and also at the University of Bristol and Cardiff Metropolitan University, and Emma Pagnamenta of the Psy – the School of Psychology and Clinical Language Sciences at the University of Reading. Yvonne and Emma are co-authors with Faith Orchard, Tim Peters, Alan Emond, Kate Northstone, Laura Louise Miller and Sue Roulstone of a paper entitled, “Social, Emotional and Behavioural Difficulties Associated with Persistent Speech Disorder in Children: A Prospective Population Study’’, recently published in JCPP Advances.
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Yvonne, Emma, thank you for joining me. Could we start with some introductions, maybe say who you are and what you do?
[00:01:25.159] Dr. Yvonne Wren: Hi, Mark, my name’s Yvonne. I’m Director of Bristol Speech and Language Therapy Research Unit, which is based at Southmead Hospital and is part of North Bristol NHS Trust. I’m also Associate Professor of Speech and Communication at the University of Bristol and a Reader in Speech and Language Therapy at Cardiff Metropolitan University. And my role, across all three of those institutions, is to lead research which has potential for impact in the fields of speech, language and communication development and disorder across the lifespan.
[00:01:53.700] Dr. Emma Pagnamenta: And I’m Emma. I am a Speech and Language Therapy Lecturer and I’m a practicing Speech and Language Therapist at the University of Reading. I am Co-Lead of a research group called the Speech, Language and Communication Development Group and also Co-Lead for Health at the Centre for Literacy and Multilingualism at Reading. I am really particularly interested in the outcomes of communication needs in childhood and also thinking about what we can do to support children that have these communication needs. And this is something that’s come out of my clinical practice and also my research work and working for our professional body.
[00:02:25.530] Mark Tebbs: Thank you for joining us. Let’s turn to the paper: “Social, Emotional, Behavioural Difficulties Associated with Persistent Speech Disorder in Children: A Prospective Population Study” recently published in JCPP. Could you give us just a brief overview of the paper to set the scene?
[00:02:41.150] Dr. Yvonne Wren: So, the background to this is we all really know, from evidence in the literature and from clinical experience, that children with speech, language and communication needs are more likely to experience social, emotional and behavioural difficulties in older childhood and adolescence. But the problem with this is that speech, language and communication needs is a very broad term, and we need to understand whether this is something which is relevant for all children with all types of speech, language and communication needs, or whether some are more impacted than others. So, there’s a fair bit of research, which has already been carried out with children with developmental language disorder and this has shown that there’s a greater proportion of social, emotional and behavioural difficulties in this population.
So, what we wanted to do was to see whether similar patterns are observed for children with persistent speech disorder. And just to explain what we mean by that term, “persistent speech disorder,” we mean children whose speech is different from their peers because they use the wrong sounds in words, or the sounds that they use are distorted or missed out altogether. And this has an impact on how they sound when they talk and also an impact on their intelligibility, particularly to people who don’t know them well. And there’s a whole range of reasons why they might have these problems, but in fact, in the majority of cases, there is no identifiable cause.
What we did, in this research, was we compared children with persistent speech disorder with children whose speech was typically developing. And it showed that those with persistent speech disorder were more likely than other children to have problems with peer relationships. So, it means that both parents and Teachers were more likely to say that these children were rather solitary, they played on their own, they didn’t have at least one good friend and more likely to get picked on by others, so that sort of thing.
Now, interestingly, Teachers, but not parents, also reported that these children were more likely to be emotional and by this, we mean that the Teachers said that the children were “nervous, clingy, unhappy, fearful,” and they were “more likely to have worries” and also “complain of headaches.”
We also looked at whether the children, with persistent speech disorder, were more likely to show signs of depression and also be involved in antisocial or risk-taking behaviour. The initial analysis did suggest that the children were more likely to show signs of depression, but actually, when we included other factors in the analysis, so things like children’s language skills, social economic status, biological sex, that association was lost. So, this is encouraging, but the data that we were looking at was when children were only ten or 11, so it’s possible that a relationship with depression might emerge later. We didn’t find a relationship with antisocial or risk-taking behaviour, but again, we can’t completely rule this out, as it might start to appear when the children are older.
[00:05:24.710] Mark Tebbs: Brilliant, thank you. You touched on it, but could you explain why you decided to focus study on this area?
[00:05:29.730] Dr. Emma Pagnamenta: Do you mean in terms of the speech sound disorder…
[00:05:31.900] Mark Tebbs: Yes.
[00:05:32.900] Dr. Emma Pagnamenta: …particularly? The main reason for this is that we know quite a bit about some other types of speech, language and communication needs and the long-term impacts of those. So, things like developmental language disorder, for example. There’s been quite a lot of work done over time looking at longitudinal dataset and large-scale studies, and we know that there are impacts of those kinds of communication needs on social, emotional, behavioural needs, in terms of wellbeing, in terms of peer and relationships.
We thought, well, what about this group, then, a group of children that have got these very persistent speech sound difficulties? And that seems to be a gap, but it is very prevalent. So, a lot of children we see, as Speech and Language Therapists and seen in school, do have this type of need and in fact, some work conducted by Yvonne previously has found the prevalence of children, who still have ongoing needs with speech beyond the age of eight, is around 3.6%. So, this is an important group.
But further to all of these points is really what we see in practice, and this is where we meet families with a child who has real difficulties getting their message across because their speech is really unintelligible, and they’re getting very frustrated and the families are telling us, you know, “My child is not able to make friendship. Can’t get their message across” in their schools, or in their preschools, or so on, and they’re really concerned, and they want to know, “Will my child be okay?” And part of that, of course, is they want to know if their speech is going to be okay and whether intelligibility will improve, but it’s much more than that. It’s parents are worried, you know, “Will my child be able to make friends? Will they be able to do okay at school? And what about the long-term impact in terms of wellbeing?” And so, that is really where we came from in thinking about this study.
There’s also another point, I think, that was important, it’s where the – it’s really, what do we know about these long-term impacts and what can that tell us about making a case for intervention with these groups? Because we know, actually, for children with speech sound disorder, we do have effective interventions that work and so, if we can show that there are long-term implications, then maybe that makes the case for intervening earlier on.
[00:07:24.430] Mark Tebbs: Yeah, thank you. In the paper you, kind of, mention a number of core questions that, kind of, drove the research. Could you describe those for listeners?
[00:07:33.199] Dr. Emma Pagnamenta: Yeah, so, as I’ve mentioned, the starting point for this, really, was, you know, this, sort of, question coming from parents about will their child be okay? And what we wanted to do is look at this specific group of children beyond the age of eight who are still having these persistent difficulties. And we really wanted to understand whether these children would be more likely to present with social, emotional and behavioural difficulties later on. And as I’ve mentioned, this was really borne out of the work that we know around other different sorts of communication needs, and whether we would see something similar with this population.
It makes sense, you know, these children/young people are experiencing frustration in getting their message across and building those relationships and communicating, that it may well then have these impacts on these kinds of difficulties later on. So, beyond that, we do also want to look at symptoms of depression and we’re also interested in terms of antisocial and risk-taking behaviours later on in older childhood and that, again, is because what we know of these other conditions where we’ve seen some of these links emerging, we were, kind of, interested to know wheth – is speech sound disorder similar or different in those ways?
[00:08:37.560] Mark Tebbs: Excellent, and could you describe how you went about it? So, describe a little bit about the methodology for the study.
[00:08:45.260] Dr. Yvonne Wren: Yes, that’s probably one to come back to me for. So, this study used an existing dataset. Specifically, we used a large longitudinal, transgenerational, community population study and this study’s been following families for over 30 years. Its main aim is to investigate the health and development of children and it’s looking at both parent and, indeed, grandparent factors and also environmental factors and how they influence health and development of children. So, speech, language, social and emotional, behavioural difficulties, those are just a very small part of this immense dataset.
The study is known locally, in Bristol, as the “Children of the 90s” and it recruited many families of babies that were born in the early 90s. But its official title is the “Avon Longitudinal Study of Parents and Children,” or ALSPAC for short, and that’s how I’ll refer to it from now on, ‘cause it’s a very long title. It’s worth noting that ALSPAC data is available for anybody to use, and you can do an easy Google search on ALSPAC. That’s spelt A-L-S-P-A-C and then, you’ll find the ALSPAC website on the Bristol University webpages, and there’s lots of information there about the kinds of data that’s available and also how to access it. There’s much more than speech and language and social-emotional needs. So, if you’ve got any interest in children’s health and development, do have a look on the website there.
So, ALSPAC collect masses of data and we were able to use data collected on a sample of over 7,000 children who attended for speech assessment at age eight, and we could determine which of these children had persistent speech disorder from recordings that were collected at that time. So, specifically, what we did, we asked children to talk to us. We got them to describe pictures and do a couple of other tasks, as mentioned, so that we had a sample of them speaking in continuous sentences. We then transcribe that and then, we analyse those transcribed samples, and we use a measure called Percentage Consonant Correct, and quite simply, what this means is that you add up all the consonants that a child produced in a speech sample, and then, you add up how many of those they produced correctly. And it’s a fairly standard measure that we use in speech analysis, and is reported often in the literature.
So, we use that to determine which children could be classified as having persistent speech disorder, so that was the first step. And there’s a lot more detail about that in the paper, but that’s a bit of a overview of how we did that. So, then we compared the children who we classified as having persistent speech disorder with those who had typically developing speech. We used regression analysis to then look at the relationships between having persistent speech disorder and also displaying one or more of a range of social, emotional and behavioural difficulties. And the data on these social, emotional, behavioural difficulties were collected over a period of time, and mostly when the children were aged ten or 11, and the exception to this was in the question about, “Have you got involved in smoking cigarettes?” and that was asked of the children when they were 14.
In the analysis, we also adjusted for known confounders, so in other words, things that might also influence a child’s likelihood to have social, emotional and behavioural difficulties. So, specifically, we adjusted for social economic status, and we used a measure of the mother’s final educational attainment, we used that as a proxy for social economic status. We also adjusted for biological sex and the other thing that we adjusted for was children’s language skills, sorry, children’s IQ, their verbal and non-verbal IQ. And this was quite important, because we already know that children’s language skills, so their ability to put words together in sentences and understand words, etc., is associated with certain social, emotional, behavioural needs. So we needed to make sure that it was specifically speech that we were seeing a relationship with and not speech and language.
[00:12:40.410] Mark Tebbs: Yeah, and it’s a huge dataset and sample, isn’t it?
[00:12:44.100] Dr. Yvonne Wren: Yes.
[00:12:45.100] Mark Tebbs: So, could you, sort of, describe what was unique about the way that you went about the study?
[00:12:49.540] Dr. Yvonne Wren: Well, I think the uniqueness relates to the dataset. You know, we’re extremely fortunate to have ALSPAC as a resource and it is available for anyone to access and use. It’s an absolutely incredible resource. That is hard to overstate what an amazing study it is and the breadth and depth of data in it. There have been other studies that have looked at the relationship between speech, language and communication needs and social, emotional and behavioural outcomes, as I said at the beginning, but often, they’ve used clinical samples. So, that means that children who never make it as far as accessing or being referred to clinical services, they’re not included in those studies.
In the past, with other cohort studies, where cohort studies’ data has been used, often, what’s happened is that children with speech, language and communication needs have been grouped together. There are studies that have looked at children with speech needs, but actually, when you go into it, it includes children who stammer, children who have voice problems, etc. And we wanted to just focus on children with speech sound needs, and ALSPAC has that data.
The other main way in which the work is different in terms of using the ALSPAC data is that they have this depth of data that’s not available in other epidemiological studies. So, often, birth cohort studies will rely on parent report and that’s completely understandable. Any large study involving children is very difficult and expensive to administer, so you often rely on parent questionnaires, and ALSPAC does that as well, but ALSPAC also collected direct data from children by running these research clinics. So, the children were assessed on a whole range of different measures, of which speech and language is just one. Because we have these speech recordings, we could listen to those recordings, we could transcribe them, we could analyse them and that’s far – a far richer dataset than any others that have been used to look at these sorts of questions in the past.
[00:14:37.019] Mark Tebbs: Yeah, and you used the Strengths and Difficulties Questionnaire and an adapted version of the Short Moods and Feelings Questionnaire. Could you describe those tools and how they were used in the study?
[00:14:49.030] Dr. Yvonne Wren: So, the Strength and Difficulties Questionnaire, or SDQ, is used quite a lot. You’ll find it reported in a lot of research papers. It’s a brief behavioural screening tool and it can be completed by parents and Teachers; it only takes about five minutes. It contains 25 questions, and those questions represent both positive and negative features associated with five subscales. And the five subscales are emotional symptoms, conduct problems, hyperactivity and inattention, peer relationship problems and prosocial behaviour. And so, in ALSPAC, the parents were asked to complete the SDQ when the children were 11 and the Teachers were asked to complete it for children when the children were in their final year of primary school. So, in the UK that’s when they’re aged ten or 11.
The Short Moods and Feelings Questionnaire contains 13 statements, and this is a self-report screening measure of childhood depression. So, this was used when the children came in for one of these research clinics that we’ve talked about. So, it’s when they came into the clinic at age ten, the 13 items were read aloud to the children and then, they were asked to indicate how they’d been feeling in the previous two weeks and whether the statement was “true, sometimes true,” or “not at all true” in the previous two weeks. And the statements were things like, “I cried a lot, I didn’t enjoy anything at all, I found it hard to concentrate.” They’re all negative statements, but there are only 13 of them, so it doesn’t take that long.
So, we used these as the outcome measures for the social and emotional difficulties part of the analysis that we carried out. They’re both screening instruments, rather than clinical tools, but they have been designed for use in epidemiological studies. It’s just not appropriate or viable to carry out a full clinical assessment, but both of the tools have been validated against clinical instrument and so, we know that they do distinguish between children with and without social and emotional needs.
[00:16:40.180] Mark Tebbs: And were there any results that were particularly surprising to the team?
[00:16:43.980] Dr. Yvonne Wren: Yes, I think we were surprised that we didn’t see an increased rate of behavioural problems, that these children aren’t showing antisocial or risk-taking behaviours, because we know that these behaviours have been observed in the more generic category of children with speech, language and communication needs. But I think it’s important to bear in mind that this doesn’t necessarily mean that this isn’t a problem for this group and that maybe what’s being observed by the Teachers, when they’re reporting greater levels of emotionality, is a different kind of response. It’s not necessarily behaviours which might be perceived as bad or disruptive, but perhaps children with persistent speech disorder become more withdrawn. And I think the danger with this is that these are children who then are perhaps more likely to be missed.
If you’ve got a child who is showing antisocial, risk-taking behaviour that is disruptive, Teachers tend to want and need to do something to respond to that. Whereas if a child is withdrawn, that is a concern, but when you’re faced with a child who’s throwing a chair across the room, that is the more immediate concern. So, possibly, these children are more at risk of being missed than children who show those risk-taking and disruptive behaviours.
Also, the finding that there’s no additional risk for depression once there’s adjustment for confounders was surprising, again, given that Teachers reported these greater levels of emotionality. But the data that was used for this was self-report from the children. I think perhaps we can consider, is it that the Teachers are seeing something that, almost, the children aren’t recognising themselves yet? Perhaps it’s too early, they’re too young for us to start seeing these signs at age ten. And I did mention this at the beginning and I think it’s perhaps important that we go and look at this question again when they’re older, and it would be great if we found the same finding, that there’s no increased risk of depression, but I think we do have to look into this.
[00:18:30.039] Mark Tebbs: Yeah, I’d like us to, kind of, move onto the implications of the study. Is there any advice for practitioners?
[00:18:36.230] Dr. Emma Pagnamenta: When we think about implications, it – I think there’s some really important things that have come out of this work into the awareness of speech sound disorder and the possible impacts and implications of those. And when we’re thinking about practitioners across health and education, I think it’s important for us all to be aware of children that currently have these problems, but may, in fact, be older, in adolescence, who may have a history of speech sound disorder. Not currently be presenting with significant needs from that perspective, but have that history and therefore, may be more likely to have these impacts and social-emotional needs. And also thinking about the degree of which have a history or current persistent speech disorder, but may have other comorbidity with those speech and language difficulties.
But thinking of these groups together, then, we need to have an awareness of who these children are, really take note of their history and whether they’ve had these difficulties in the past and then, be aware of what that might mean, then, in terms of through their schooling years and how their needs may change over time. So, we may see that some needs emerge, some become more important, you know, peer relationships and so on, and the emotionality.
So, there’s that around awareness and identifica – of who these children are. There’s then the need for us to be aware of these kinds of difficulties that these children may face and then, of course, it’s about what we do about that, then. So, we need to be doing ongoing monitoring of how these children/young people are doing over time, and then we need to be ready to do something about it. So, we need to think about – looking out for these things and thinking about onward referrals, or getting that support in place, early intervention, to try and reduce these impacts, if we can.
And then, I think the final point to make on this is really about this evidence that shows that there would be benefits of intervening earlier to reduce these potential negative sequalae of persistent speech disorder and that’s a really important point, I think, for practitioners.
[00:20:31.280] Mark Tebbs: Yeah, thank you, and for parents and carers, are there any messages from your study then?
[00:20:37.360] Dr. Emma Pagnamenta: I think what we would want to say to parents and carers is, “If your child still has persistent problems with speech by the age of eight and later on, it’s true that they may be more vulnerable to some impacts later on, or that that’s what we understand from this research. But we’re not saying that all children will,” and as Yvonne said, “it’s really that they’re more likely to.” And so, I think parents being aware of that is helpful, because they can be then looking out for those signs and be ready, then, to do something about it.
[00:21:05.789] Mark Tebbs: Brilliant, and I’m just wondering, also, about any policy implications. Is there anything that needs to change at that, kind of, policy level to see the improvements in outcomes for young people with persistent speech disorders?
[00:21:18.630] Dr. Yvonne Wren: Yes, I think there are changes that need to happen. I think we’ve seen a reduction in the amount of speech and language therapy support for children with speech sound disorder over recent years, in particular, but it’s been a gradual decline. We need to reduce the number of children who have persistent speech disorder, and we need to reduce the severity of that persistent speech disorder when it does persist. And the way to do that is to get in when children are younger so that these problems aren’t persisting. We know about the impact on education. We’re now seeing the impact on social and emotional wellbeing.
The amount of speech and language therapy, which is available to children today, is shockingly small and it’s not enough to make a difference if we look at what the evidence in the peer reviewed literature tells us and often, these children are just getting a very small number of sessions. You can’t resolve these kinds of needs without a sustained amount of input and getting this input before they start school, or very much in the early stages of schooling, will reduce the likelihood of having these knock-on impacts on social and emotional wellbeing. And if we don’t do that, then what happens is the burden for these needs just passes on to Teachers and they’re already struggling to deal with classes with children with a range of additional needs.
We know that, as I’ve said, these children could often be overlooked and even the best Teacher in the world would struggle not to do this with the amount of need that they’re dealing with in schools, that our Teachers are highly skilled, but they can’t be experts in everything. So, if these problems aren’t dealt with in early life and they don’t simply go away, we end up with children who are not doing as well at school as they could be, children who have ongoing needs with wellbeing as a result of sounding different, having fewer friends, being picked on by others and showing more signs of being emotional or vulnerable. And then, there’s the expense of responding to these needs and helping adults who have not fulfilled their potential and may struggle to be both economically and socially independent because of a history of persistent speech disorder.
So, yeah, the policy implications are tricky, because greater investment’s needed, but the investment is needed when they’re young and if we can reduce the prevalence, persistence of speech disorder, reduce the severity of the speech need and provide support for the emotional needs of children and also those trying to support them, then we may reduce the long-term impact of this. But I think awareness is key and that needs to be the starting point, and awareness that’s not just about speech, but also so much more, and then we can do more, as well. And if we can do more when they’re young, we can reduce the burden on healthcare for those young people who carry the scars of early experience of childhood speech disorder.
[00:23:51.770] Mark Tebbs: Yeah, it’s such an important area. I’m just wondering, are you planning any, kind of, follow-up research, or is there anything in the pipeline that you’d be able to, kind of, share with us?
[00:24:01.890] Dr. Yvonne Wren: Yes, in fact, we have a paper coming out which has also used ALSPAC data, and that’s going to be published in the Journal of Speech and Language and Hearing Research, published in spring 2023. And that’s looking at the relationship between atypical speech development and adolescent self-harm, and I do want to make the point again that an increased risk of showing a negative outcome like self-harm does not mean that every child with persistent speech disorder will show that. But it does mean that there’s an increased risk and obviously, this will be reported in the paper, but it’s a concern.
We also want to build on the work in the paper we’re discussing today, and we’ve already said that, you know, we think it’s really important that we look at these children when they’re older, particularly to see whether depression starts to become a factor. We hope not, but we do think it’s important that we look.
[00:24:50.659] Mark Tebbs: Thank you, and finally, is there a take home message for our listeners?
[00:24:55.630] Dr. Yvonne Wren: I would say that the take home message is that if a child has a speech disorder, particularly one which is persisting into the early school years, then they may have other needs as well, particularly with friendships and peer relationships and also with showing signs of feeling emotional at school. We need to support these children, not just with their speech, but also with their friendships and their feelings. We need to bear in mind that the kinds of approaches we might use with other children who show problems with friendships and feelings, might not work so well for this population and the reason is because we often draw on approaches that involve talking and talking is difficult for these children. They can talk, but they may be reluctant to talk. They may find it difficult to make themselves understood. So, we need to bear that in mind and have alternative approaches when talking isn’t going to work for these children, if they’ve got problems with friendships and problems with feelings, particularly at school.
[00:25:49.190] Dr. Emma Pagnamenta: Well, I completely agree with you, Yvonne. I would only really add that I think one thing that’s really important is about the awareness, the awareness of speech sound disorder and the possible impacts of this, and we hope that this study will play a part in raising levels of awareness about this more widely. But I’ve talked to parents and families, and they explain their journeys with the young people, about how they constantly have to educate professionals, act as advocates, because people just don’t understand what speech sound disorder is or what other types of communication need is. And if by doing this work, we can, kind of, limit the burden on parents and spread these, sort of, messages and this awareness more broadly, I think that would be, you know, a really good outcome of the work.
[00:26:30.230] Mark Tebbs: Brilliant. Thank you so much. It’s a really important study and it’s been a really fascinating conversation. So, for more details about Yvonne and Emma, please visit the ACAMH website, www.acamh.org and Twitter @acamh. ACAMH is spelt A-C-A-M-H, and don’t forget to follow us on your preferred streaming platform, let us know if you enjoy the podcast, with a rate or review, and do share with friends and colleagues.