Child Language Teaching and Therapy 20,3 (2004); pp.

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The ICF: a framework for setting goals for children with speech impairment
Sharynne McLeod School of Teacher Education, Charles Sturt University, Bathurst, NSW, Australia and Ken Bleile Department of Communicative Disorders, University of Northern Iowa, Cedar Falls, Iowa, USA

Abstract
The International Classication of Functioning, Disability and Health (ICF) (World Health Organization, 2001) is proposed as a framework for integrative goal setting for children with speech impairment. The ICF incorporates both impairment and social factors to consider when selecting appropriate goals to bring about change in the lives of children with speech impairment. Speechlanguage therapists and teachers can work together not only to provide direct intervention with the child, but also to work in partnership with the childs family, friends, school and society. Children with speech impairment constitute one of the largest groups of children with a communication difculty (Harasty and Reed, 1994). Difculty producing sounds as preschoolers may have inuence on their subsequent educational, occupational and social opportunities throughout life (Felsenfeld et al., 1992; 1994). Thus, it is essential that careful planning occurs to ensure that the goals set for these children and their families facilitate successful lifelong communication. The aim of this paper is to provide speech-language therapists (SLTs) and teachers with a meta-theory to scaffold their daily decision making regarding children with speech impairment. Traditionally SLTs and teachers in special education have relied on an impairment-based model of decision making. The origins of the impairment model may be attributed to the medical and behavioural origins of the professions.
Address for correspondence: Sharynne McLeod, School of Teacher Education, Charles Sturt University, Panorama Ave., Bathurst, NSW 2795, Australia. E-mail: smcleod@csu.edu.au
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According to Duchan (2001a: 37) proponents of the impairment view presume that the communication problem is in the client and that it can be remedied by providing the client with missing knowledge or processing skills. Thus, following the impairment-based model, childrens speech is assessed according to standardized assessment tools, their production of speech sounds is compared with available norms, and decisions regarding the existence and=or extent of impairment are made. Subsequent impairment-based goals could include increasing speech sounds within a childs repertoire, decreasing the occurrence of cluster reduction, or expanding the syllable shapes used by the child. The impairment-based model relies heavily on the expertise of the professional (in this case the SLT) who typically conducts the assessments and analyses, and determines goals based on areas of impairment. The family and teachers have less input into the goal setting in the impairment-based model (Reynolds, 1984). Alternatively, many teachers and some SLTs have adopted a social model of decision making. In the social model, . . .therapy plans centre around selected life goals and what needs to be done to achieve them (and) . . . emphasize the communicative impact of the clients differences rather than the clients decits. (Duchan, 2001a: 38, 39). Some proponents of the social model also present disability as a part of life and the source of the problem as a society that is not inclusive of people with disability (Hersh, 1999; Jordan and Kaiser, 1996). A social model of goal setting validates and necessitates extensive support from the family, teachers, and the children themselves as the experts. Thus, the role of the teacher and SLT is to facilitate the dialogue toward the development of socially appropriate goals. For example, the SLT might ask about events that made the child feel particularly good, and particularly bad during the current school year (Nelson, 1989: 176) and use these critical incidents as a framework for identication of relevant goals. Both impairment and social models can be valid (for an insightful debate see the Clinical Forum led by Duchan, 2001a). A meta-theory that draws on both the impairment and social models has been developed by the World Health Organization (WHO, 2001). The initial version (WHO, 1980) was grounded in a medical (impairment) model and used the terms impairment, disability, and handicap. The nal version integrated impairment and social models to describe the health and health-related status of all people and is called The International Classication of Functioning, Disability and Health (ICF) (WHO, 2001). There are two parts to the ICF. Table 1 illustrates the interactions between the parts and components of the ICF. Part I is titled Functioning and disability and describes health from the perspectives of the body, the individual and society and includes the components of body structures, body functions, activities and participation. Body structures refer to the anatomical parts of the body, such as

Table 1 Application of ICF to a speech and language assessment in order to inform goal setting

ICF parts
  

ICF components Socially-based goals

ICF descriptors relating to communication

Possible components of an SLT assessment and analysis Impairment-based goals

I. Functioning and disability

  

Body structures

Anatomy of nose, mouth, pharynx, larynx Genetic material

Conduct an oromuscular examination and audiological assessment Request a medical examination

 

Surgical repair of craniofacial anomaly Cochlear implant

Promote societal acceptance of diversity of the appearance of people Encourage daily nose blowing to reduce occurrences of otitis media

Body functions
   

Production and quality of voice Articulation of phonemes Expression of spoken language



Conduct assessment of speech sounds= phonological processes, voice and language Analyse speech and language sample Request an educational assessment of reading and writing


Reduce audible nasal emission during the production of high-pressure consonants Establish stable and accurate productions, thus reducing the variability of errors


Increase intelligibility by decreasing the use of phonological processes contributing to unintelligibility (cf. Hodson and Paden, 1981) Reduce speech patterns that are unusual (e.g., initial consonant deletion) or not considered to be normal errors (Smit, 1993) Correctly produce phonemes that have a high frequency of occurrence

 

Activity and participation (consider performance versus capacity)

  

 

The ICF as a goal-setting framework

Conduct intelligibility assessment Gather qualitative descriptions of successes and difculties in participation in the family, school, social situations

Communicating with receiving spoken messages Speaking Conversation Learning and applying knowledge including learning to read and write Interpersonal interactions and relationships

Correctly pronounce the childs name as well as the names of signicant others Pronounce words the child would like to say and=or has been teased about

Collaborate with the childs teacher to promote communicative success, including strategies to repair communication breakdowns Work with a childs peers on awareness of communicative breakdown and strategies to use; e.g., asking for repetition, or show me

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Table 1 Continued

ICF parts


ICF components Socially-based goals

ICF descriptors relating to communication Impairment-based goals

Possible components of an SLT assessment and analysis

Preschool education Community, social and civic life

Promote communicative success by maintaining a diary of signicant events that the child may want to communicate and keeping a list on the fridge of the childs pronunciations of important words

II. Contextual factors

 

Environmental factors

Child Language Teaching and Therapy

 

Products and technology Support and relationships Attitudes Services, systems and policies


Determine parental, wider family and school involvement and support Determine attitudes and expectations of the childs family and community regarding social, occupational and educational aspirations Determine governmental policies regarding the number of funded intervention sessions, etc. Discuss the inuence of: age of child, selfcondence, motivation, attention, cognitive ability, beliefs, learning style, and experience with communication failure

Personal factors


Attributes of the person, and the internal inuences on functioning and disability

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the nose, mouth, pharynx and larynx. Body functions describes the physiological functions of body systems (WHO, 2001: 10). Included in the category of body functions are voice functions such as production and quality of voice, speech functions including the articulation of phonemes, and mental functions of language including expression of spoken language. Activity is the execution of a task by an individual (WHO, 2001: 10) and participation describes the involvement in a life situation. Thus, under the heading of activity and participation, communication in its many forms is included as an entire chapter within the ICF (chapter 3). Some of the highlighted aspects of communication include Communicating with receiving spoken messages, speaking and conversation. Other relevant categories of activity and participation include learning and applying knowledge (chapter 1) such as learning to read and learning to write. Additionally, activities and participation include interpersonal interactions and relationships (chapter 7), major life areas such as preschool education (chapter 8), and community, social and civic life (chapter 9). Finally, the term disability serves as an umbrella term for impairments, activity limitation and participation restrictions (WHO, 2001: 3). Part 2 of the ICF is titled Contextual factors and includes environmental and personal factors (see Table 1). Environmental factors make up the physical, social and attitudinal environment in which people live and conduct their lives (WHO, 2001: 10) and can be facilitators or barriers. Environmental factors relevant to communication include products and technology (chapter 1), support and relationships (chapter 3), attitudes (chapter 4), services, systems and policies (chapter 5). Personal factors include the attributes of the person, and the internal inuences on functioning and disability. Due to the individuality of this WHO component, personal factors are not specied as chapters within the ICF. Within the eld of communication disorders, there has been some use of the ICF (and its predecessors) as a meta-theory for practice (for example, American Speech-Language-Hearing Association, 2001; Threats, 2000; 2001; Worrall, 1999; 2001). The application of the ICF (and its predecessors) has particularly occurred within the context of SLTs working with adults who have dementia, experienced a stroke, or acquired brain injury (for example, Bourgeois, 1998; Hersh, 1999; Worrall, 1999), with adults who have voice disorders (Ma and Yiu, 2001a; 2001b) including those who use alaryngeal speech (Eadie, 2003). There have also been some descriptions of the use of a social model of interaction in speech and language practice with children (for example, Duchan, 2001a; 2001b; Kovarsky, 2001; Locke, 2000), but limited direct application of the ICF to the consideration of the speech of children. The exception is the excellent work by Hodge (1983) who applied the original 1980 version of the WHO model to assessment and intervention practices with a child who had a speech impairment.

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In order to explore the application of the ICF to child language teaching and therapy, each of the parts and components of the ICF will be discussed with relation to childrens speech production. Table 1 lists each of the parts and components of the ICF and their application to a speech and language assessment in order to inform goal setting. Many of these assessments and analyses are typically included in traditional SLT assessments (see the forum led by Williams, 2002). For example, oromuscular examinations and audiological assessments are conducted to assess body structures. An SLT assessment of speech sounds and phonology are conducted to assess body functions. However, it is less likely that SLTs consider activity and participation, contextual and personal factors. Conversely, teachers frequently consider activity and participation of children. Possible methods of evaluating activity and participation include an intelligibility assessment, or by gathering qualitative descriptions of successes and difculties in participation in the family, school and social situations. Determination of parental, wider family and school involvement, support, attitudes and expectations comprises evaluation of contextual factors. Personal factors can include the age of the child, self-condence, motivation, attention, cognitive ability, beliefs, learning style, and experience with communication failure on intervention. Although there is close interrelationship between each of these areas, goals will be suggested for parts and components.

Goals targeting functioning and disability

Body structures and functions Children who are described as having a communication impairment of (known) origin usually have impaired body structure(s). Impairment of body structures can include a cleft palate, anklyglossia or a malformed cochlea among other examples. Impairment-based goal setting for children with impaired body structures often includes medical intervention such as surgical repair of a cleft, or a cochlear implant. With the advancement of medical science, there is the potential for a decreasing need for extensive speech intervention for people with impairment of body structures. For example, Golding-Kushner (1995: 327) has written that Approximately 80% of children born with nonsyndromic cleft palate who undergo palate repair by 18 months of age develop speech free from compensatory errors without any type of therapeutic intervention. A social goal addressing impairment of body structures could aim to promote societal acceptance of diversity of the appearance of people. For example, a popular television show could include a child who has a craniofacial anomaly in order to promote inclusiveness.

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Impaired body structure can result in impaired body function. For example, a person with a cleft palate may have nasal emission during speech. An impairment-based speech goal could therefore include reduction of audible nasal emission during the production of high-pressure consonants (stops, fricatives and affricates) (Harding and Grunwell, 1998). This may have the social advantage of being more intelligible and less different or obtrusive. Other, more subtle impairments in body structure and function that inuence speech production can be detected via oromusculature examination (for example, Ozanne, 1992; Robbins and Klee, 1987), with examples of impaired body structure including tongue-tie and examples of body function impairment include difculty on diadochokinesis (rapid speech movement) tasks. Debate exists as to the impact on speech production as a result of these more subtle impairments of body structure and function. Similarly strong debate surrounds the use of oral-motor exercises to facilitate speech sound acquisition in children with speech impairment. Lof (2003: 9) provides a summary of this debate and concludes the there is little, if any, theoretical, philosophical, or clinical justication for using oral motor exercises to improve speech sound production skills. Impairments of body structure and function relating to hearing can be detected via audiological examination, such as tympanometry. An example of impairment of body structure is otitis media (glue ear), while an example of body function impairment is hearing loss. Controversy surrounds the interrelationship between otitis media (impaired body structure) and speech perception=production (body function). Shriberg et al. (2000a; 2000b) has altered the debate about whether or not otitis media is the cause of speech impairment, to the notion that there is increased risk of speech impairment as a result of occurrences of otitis media. However, Campbell et al. (2003: 353) found that persistent otitis media in the rst three years of life did not signicantly increase the risk of speech delay after controlling for relevant covariates. A social intervention relating to aural body structure and function differences is the Healthy Little Ears project, a health promotion project with children in Australia (Mid Western Area Health Service, 1999). Within this programme children are encouraged to blow their nose each day to increase functioning of the eustachian tube and decrease the occurrence of otitis media. Genetics research has opened new areas of knowledge of impairment at the micro level of body structure. It may be the case that genetic abnormality may account for children exhibiting impaired body function but previously thought of as having intact body structures. For example, Lai et al. (2001) described the FOXP2 gene chromosome 7 as relating to speech apraxia. Flipsen et al. (2001)

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have described acoustic markers that are indicative for genetic studies of speech impairment. The inuence of these genetic breakthroughs on goal setting in speech intervention may include discussion of familial histories (for example, Lewis et al., 1989; Lewis and Freebairn, 1993) and genetic counselling. Early intervention opportunities may be made for younger family members of the child referred for speech intervention. Early identication can also lead to intervention opportunities to support academic success, particularly with respect to reading and spelling (Lewis et al., 2000). To date, the majority of children who are seen by SLTs have communication impairments of unknown origin (Shriberg et al., 1986), indicating that their body structure is considered to be intact. These children have difculty with body functions such as the production of speech sounds. Traditional SLT measures of the speech function of these children have included the array of articulation=phonology tests such as the Edinburgh Articulation Test (Anthony et al., 1971) and the Computerized Articulation and Phonology Evaluation System (CAPES) (Masterson and Bernhardt, 2002). The range of speech analyses includes phonological analyses [for example, Prole of Phonology (PROPH ), Long et al., 2002]; nonlinear analyses (Bernhardt and Stemberger, 2000) and psycholinguistic analyses (Stackhouse and Wells, 1993). Additionally, objective measures, including acoustic (for example, spectrographic) and physiological (for example, electropalatographic; Gibbon, 1999) tools are enabling more accurate description of speech (Ball et al., 2001). Children with speech impairments may receive assessment reports concluding with impairment-based goals such as to increase the percentage of consonants correct (PCC), decrease the occurrence of various phonological processes, or to produce a list of phonemes expected but not produced correctly by the child. For children with impaired speech function, there has been extensive debate among SLTs regarding appropriate intervention goals. Two dichotomous approaches to goal selection have been proposed. First, the most knowledge method (also called the traditional, or developmental approach) and second, the least knowledge method (nontraditional, nondevelopmental approach) (Bleile, 1995). For the most knowledge method, intervention goals differ minimally from the sounds the child already produces (Elbert and Gierut, 1986). That is, sounds or phonological processes are selected as intervention goals because they are earlier developing, stimulable and produced correctly in particular contextual environments (Bernthal and Bankson, 1998). In contrast, in the least knowledge method . . .treatment targets differ from the childs existing abilities by multiple features (Elbert and Gierut, 1986). Therefore, sounds or processes are selected because they are nonstimulable, phonetically more complex, have phonologically marked properties, reect least phonological knowledge as

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categorized by inventory constraints (with respect to phonemes) and are later acquired (Gierut et al., 1996). Gierut (1998) provides evidence that treatment goals are achieved efciently if children are taught sounds or sound pairs that are not in a childs pretreatment repertoire and developmentally later-acquired sounds that are phonetically more complex, acoustically undifferentiated, and nonstimulable; that is, following the least knowledge approach. In contrast, Rvachew and Nowak (2001) compared the most knowledge (traditional) and least knowledge (nontraditional) approaches for 48 children with moderate to severe phonological disorders. The study had four major ndings: children made more progress toward acquiring target sounds through a traditional approach; the approaches did not differ in generalization from treated to untreated sounds; children liked both approaches; parents were more favourable to the traditional approach. These authors have debated their different interpretations of the outcomes of selecting the traditional and nontraditional approaches in Morrisette and Gierut (2003) and Rvachew and Nowak (2003). However, Williams (2003) adds another dimension to this debate in her helpful overview and discussion of ve approaches to target selection. As well as the traditional and nontraditional approaches, she includes markedness, the systemic function of sounds within a given sound system, contrastive sounds and lexical properties of treatment words. She concludes by advocating more research that addresses the impact of additive relationships between these different approaches. Some questions following on from these approaches to impairment-based goal selection by SLTs include the following. Should treatment goals include sounds for which the child is not stimulable (Powell, 2003)? Do children learn sounds that are stimulable without having to be taught (Elbert and Gierut, 1986; Powell and Miccio, 1996)? Should treatment goals target later-acquired sounds? Does teaching later-acquired sounds facilitate linguistic generalization more readily than teaching earlier-acquired ones (Gierut, 1998; Rvachew and Nowak, 2001)? Although these questions need to be asked, it is not possible to predict with certainty what the most appropriate goal is for an individual child. In order to appropriately answer questions such as these, SLTs need to add to their impairment-based approach focusing on body structures and functions. The ICF provides additional areas of consideration to enable appropriate goal setting for each individual.

Activities and participation The ICF model species consideration of activities and participation in facilitating health and well-being. Some that have relevance to children with

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speech impairment include: speaking; conversation; learning and applying knowledge; interpersonal interactions and relationships; community, social and civic life. Each of these will be addressed with relation to children with speech impairment. Within the last decade, SLTs have appropriated measures of activity and participation that consider (to some extent) the social impact of speaking and conversation. One measure of activity that has been formalized as an assessment practice is the level of intelligibility (Bleile, 1995; Kent et al., 1994; Kwiatkowski and Shriberg, 1992). The Childrens Speech Intelligibility Measure (Wilcox and Morris, 1999) is one commercially available sampling tool to quantify the extent of intelligibility of individual childrens speech by untrained listeners. There are few examples of ways in which SLTs consider participation within speaking and conversation by children with speech impairment. One example is the Therapy Outcomes Measure (Enderby and John, 1997), which includes a specic subsection on childrens speech. Consideration of activities and participation also includes the inuence of the impairment on learning and applying knowledge. With the high cooccurrence of children with speech impairments having reading and spelling difculties (Larrivee and Catts, 1999) it is essential that goals are developed around the facilitation of academic skills (Hodson, 1994). Intervention targeting phonological awareness should accompany speech intervention (Gillon, 2000). Partnerships between teachers and SLTs are essential for appropriate goal setting to facilitate successful oral and literate communicative skills throughout the lives of these children. Further, SLTs and teachers can consider interpersonal interactions and relationships in their intervention planning for children with speech impairment. Pertinent social assessment practices may consist of a discussion with the child, his=her parents, siblings, friends, grandparents and other signicant people to ascertain social goals and barriers, interests and hopes (Duchan, 2001a). Pretty (1995) suggested a number of goals congruent with a social model for a four-year old girl with severe speech impairment. The goals focused on the interpersonal interactions and relationships with her family, teacher, friends, peers and peers parents. For example, the teacher and SLT collaborated to promote communicative success at preschool, including strategies to repair communication breakdowns: encouraging a group of her peers to ask for repetition when they did not understand BJ, or to ask BJ to show me. BJs family were encouraged to look at her when she spoke to them; use all available cues (for example, maintaining a diary of signicant events that she may want to communicate); and keep a list of BJs pronunciations of important words (for example, the name of her best friend). These goals based

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on activity and participation can readily be adapted for any child with a speech impairment. Finally, consideration of community, social and civic life of children with speech impairment is rarely discussed. However, there is scope for socially based intervention goals to facilitate activity and participation in this context. Friends can be encouraged to spend time talking and babbling with a baby who has a craniofacial anomaly in order to develop social interactions, despite the fact that the child may look different, and have reduced time for social interaction due to the extensive amount of time spent feeding. Another example of a social goal for people with a hearing impairment would consist of public education to decrease background noise and to encourage people to look at a person with a hearing impairment while talking with them. When considering activity and participation, the ICF allows for comparison between performance and capacity. There may be a mismatch between a childs performance within their daily lives and their communicative capacity on standardized speech assessment tools. At times, children are more capable within the connes of a standardized assessment than they demonstrate within the complex communicative demands of the classroom. At other times, children exhibit a variety of compensatory strategies to minimize communicative difculty that is evident on standardized assessment tasks. Consideration of performance and capacity is an important component within the capability focus model described by Kwiatkowski and Shriberg (1993; 1998), who have successfully tested this with hundreds of children who have received speech intervention. Even while undertaking standardized assessment tools there may be a mismatch between performance on one versus another, demonstrating the mismatch between performance and capacity. Some areas of difference include: single word versus connected speech (McLeod et al., 1994; Morrison and Shriberg, 1992); imitated versus spontaneous speech (Leonard et al., 1978); stimulable versus nonstimulable sounds (Powell and Miccio, 1996); monosyllabic versus polysyllabic words (James et al., 2002). The difference between a childs communicative performance and capacity should be considered when developing appropriate goals.

Contextual factors
Environmental factors Some of the environmental factors mentioned by WHO that relate to children with speech impairment include: products and technology; support and relationships; attitudes; and services, systems and policies.

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There is a burgeoning industry of products and technology utilizing speechactivated devices for tasks such as computer operation, word processing, home banking, navigation, and telephone directory assistance. Intelligible speech is essential for the use of speech-activated devices and can place restrictions on the lives of adults who have residual speech impairments (Grifn et al., 2001). While children with speech impairment currently are not affected by this technology, if intelligible speech is not achieved by adulthood, incorporation within future society may be limited. Further, with the advances of technology, it is possible that speech-activated devices may be a common part of living for children and adults alike. Probably the most important environmental factor relating to children with speech impairment is support and relationships. The incorporation of parental support into the intervention practices is frequently a key to success (see Bowen, this issue). There is some research suggesting links between intervention outcomes and environmental factors such as socioeconomic status, maternal IQ and maternal educational level (Chan et al., 1998). Wider networks of family, friends and teachers are also important environmental inuences. Societal attitudes towards children, adolescents and adults with speech impairments are frequently negative (Crowe Hall, 1991; Madison, 1992; Silverman and Falk, 1992). For example, Silverman and Paulus (1989) compared childrens attitudes towards a child who uses=w=for=r=with a typical speaker. The child with the mild speech impairment was considered to be: less talkative and hear less well than his=her peers, dysuent, unpleasant to listen to, soft, boring, dull, more tense, nervous, afraid, handicapped, isolated, uncomfortable. Further, Anderson and Antonak (1992) found that social acceptance of an actor with a mild speech sound impairment was less positive than the same actor demonstrating a physical disability. Research by Felsenfeld et al. (1992) adds another dimension: people with speech impairment were found to be less extroverted and socialized with fewer people than people with typical speech development. Clearly people with speech impairment may be compromised by societal attitudes, necessitating goals directed towards society as well as working at the impairment level. The services, systems and policies relating to individual children are as varied as each individual and can inuence the type of schooling the child receives, the type and amount of support the child receives at school, whether a child is eligible for SLT intervention and so forth. Political factors can affect the actuality of intervention for individual clients. For example, in some health sectors within the USA, the politicization of health care dictates the number of SLT sessions a person with a particular impairment can receive. Philosophical

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attitudes toward the labelling of a child with a speech or language impairment can inuence the type of goals developed for a child (Christensen and Baker, 2002; Green and Kostogriz, 2002). For example, McDermott (1993: 272) has argued that there is no such thing as LD [Learning Disability], only a social practice of displaying, noticing, documenting, remediating and explaining it. McLeod (2003) described the distinction between the use of the terms normal and typical and SLTs role in the categorization of children along the normalabnormal divide. Simmons-Mackie (2001) described differing clinical assumptions leading to differing intervention approaches. A childs experiences of receiving intervention from different people with differing clinical assumptions is documented by Kovarsky (2001). Thus, services, systems and policies can play a role in goal setting for children with speech impairment.

Personal factors Attached to every speech impairment is a real child (Bleile, 1991). His or her unique makeup must be considered within his=her cultural milieu in order to determine the most appropriate intervention goals. The ICF (WHO, 2001: 8) recognizes the large social and cultural variance including: gender, age, other health conditions, coping style, social background, education, profession, past experience and character style. Currently, research into typically developing children has demonstrated the wide range of individual differences (for example, McLeod et al., 2001). For children with speech impairment, there are some case studies documenting the effect of personal factors on appropriate goal setting and intervention outcomes. For example, Kamhi (2000) describes the progress of phonological intervention with his daughter, Franne. Frannes stubbornness and desire to communicate with her parents led to delineation between speech sound practice with her SLT and meaningful communication with her parents. He writes: Frannes reluctance to practise speech sounds was her way to let us know that we should focus on what she said when she spoke, rather than on how she said it (Kamhi, 2000: 183). One important and documented factor to consider in the selection of speech goals is the childs personal ability to evaluate his=her speech. Self-evaluation occurs when the child judges the accuracy of his=her response prior to explicit feedback from the clinician (c.f. Koegel et al., 1986). Self-evaluation appears to be a central concept within diverse theoretical views of normal speech development and, . . .within approaches to and explications of successful intervention (Shriberg and Kwiatkowski, 1987: 154). Thus, SLTs can incorporate self-evaluation within the intervention goals.

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Conclusion: What goals are appropriate?

It can be argued that the ultimate goal of speech intervention is to bring about correct production of speech sounds resulting in intelligible conversational speech within a childs milieu (cf. Kamhi, 2000; Powell, 1991). However, other similarly important goals may be to enhance a childs participation in social interaction, to increase self-esteem, or to decrease negative societal attitudes towards people with speech impairment. The ICF is a meta-theory that allows for consideration of all these possibilities and is enhanced by collaboration between SLTs and teachers. A summary of possible goals relating to the ICF is provided in Table 1. The most important outcome of the present discussion is to reiterate that every child is unique, requiring a different approach to best meet their needs (Lowe, 1994). Thus, it is important to consider all the factors before making a decision, then to devise goals in consultation and monitor progress (see Baker and McLeod, this issue). Continual revision and consultation will result in appropriate outcomes for individual children as well as society.

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