Monthly Archives: January 2010

13. SLP Dismissal / Exits

Briefcase on the counter at the old man's bar in Paris

The “progress-in-the-general-curriculum” eligibility criterion has been in effect since the 1970s but it is never critically reviewed in its application. “In 1980, ASHA [ American Speech-Language Hearing Association ] sought and received clarification on this policy interpretation from the US Department of Education” (Kathleen Whitmire, 2002). Can a stutterer with good academic achievement be denied eligibility? The 1980 answer was no:

” … an interpretation which denies needed service to speech [or language] impaired children who have no problem in academic performance is unreasonably restrictive in effect and inconsistent with the intent of the Act and regulations…The extent of a child’s mastery of the basic skill of effective oral communications is clearly includable within the standard of “educational performance” set by the regulations. Therefore, a speech [or language] impairment necessarily adversely affects educational performance when the communication disorder is judged sufficiently severe to require the provision of speech [-language] pathology services to the child.”

This early interpretation did not anticipate many developments within the IDEA framework. It turned out that special education personnel were over-identifying at-risk children, including non-disabled children. SLPs placed non-disabled minority children with weak language skills. The stigma of placement and the need to dismiss children from special education did not receive much attention in 1980. Something closer to the “strict interpretation” was needed to balance the eligibility process. The “strict interpretation” was liberal with respect to over-placing at-risk children.

Sidewalk artist, Montmartre, Paris.

Liberal use of the impaired-communication criterion actually worked against SLPs. One speculates they stayed too close to clinical criteria and helped over-identify non-disabled children, thereby increasing their caseloads and “burnout.” It also filled in for the lack of general education pre-service programs where some speech-impaired children could receive support without stigmatization.

Educational speech-language pathology can be strengthened by clear understandings of how communication problems impact curriculum performance. Response To Intervention invites SLPs to make more decisions about prevention of academic failure from the point of view of speech and language development.

Advocated here is a broader approach to eligibility management. Each SLP should strive to minimize misidentifications and to exit children promptly. All criteria should be considered in proper balance to prevent needless placements in special education.

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12. SLP Dismissal / Exits

Once a child is made eligible for school speech therapy, aggressive use of least restrictive environment (LRE) should begin immediately to move that child toward dismissal. Try to reduce service time, restrictions and workload in an ethical manner from the very beginning.

DROP THE PULL-OUT MODEL

A school speech therapist who does “pull out” treatment 100% of the time is not following the least restrictive environment requirements of IDEA 2004. LRE contexts should be graded so that most children quickly move away from out-of-classroom instruction to consultation, support and dismissal. Combine pull out with consultation. Try collaboration. Use pre-service programs. Tune into the “progress in the general curriculum” criterion as a guidepoint.

IEP teams are more likely to accept an absolute dismissal from special education when intervention is graded away from direct service, including homework assignments and teacher consultation. More data are then available to justify dismissal.

CASE MANAGEMENT MODEL

The direct service model should be replaced by a case-management model. It gives emphasis to exit strategies using a variety of methods and contexts in a progressive and flexible manner. It lets the school speech therapist use time creatively to find relevant interventions as the child advances.

A case management approach can start with a cover statement in the IEP as to service requirements:

Service — “Minimum 50 minutes per month: goal performance assessment, direct training, teacher consultation, progress review, homework, pre-service programming.”

The cover statement does not jettison direct intervention for a few children who need a jump start. But it does allow time for intelligent re-assessment and review. It reduces the go-go stress of the weekly direct service schedule.

“Justification,” you ask?

IDEA 2004 states there must be annual goals for progress in the general curriculum, and the child must demonstrate progress yearly. It does not say — HOW? –that progress should be achieved. Pull out intervention is only one technique. Pushing a child properly into general education pre-intervention programming is another. Sending out homework assignments is another.

“When developing the intervention plan, the team should take into consideration the full spectrum of service delivery options when deciding which options are appropriate for meeting the individual needs of the child. It may be appropriate to provide a mix of options, e.g., classroom-based, individual pull-out, and consultation, to help the child establish basic speech-language skills, examine attitudes and beliefs, and apply skills in various contexts. In addition, these options should be reviewed and changed over time as needed, as the child’s needs change” (Kathleen Whitmire, SLP).

Here is an example of the caseload approach:

A 4th grade child with a neglected moderate hearing loss was supposed to receive pull out treatment for speech reading and articulation. The SLP recommended audiological assessment for possible hearing-aid use. The school secretary, principal, mother and teacher thought later there had been some kind of miracle. With aids the boy was immediately able to follow everything in his class perfectly. He was bright and had trained himself to speech read without instruction. Direct service was dropped and teacher consultation was initiated to enhance classroom support. The boy no longer had to be pulled out of class in front of the other children, and he was very much aware of their looks. His direct service time was reduced and the SLP was free to do other things. Everybody won!

CHANGING ROLE

“Isn’t pull out the best model,” you ask?

In 2008, Cirrin and Gillam published a review article suggesting there is no evidence of pull-out’s superiority over other service delivery methods. What’s more, there was no data showing that a particular number of direct sessions per week is optimal (Cirrin, F. M., & Gillam, R. B., Language intervention practices for school-age children with spoken language disorders: A systematic review. Language, Speech, and Hearing Services in Schools, 39, 110-137, 2008). This opens the door to flexible management.

With the changing role of the school speech-language pathologist in the U. S., a case-management model is just better for doing all the things an SLP has to do. It might be true that evidence-based, preschool programs, in which SLP participate collaboratively, might well reduce overidentifications, cut down on needless direct service, be more effective, increase communication with teachers, limit LRE constraints, and reduce workload, all at the same time. There is no need for dismissals when at-risk children are never placed in special education in the first place.

Are you open to it?

11. SLP Dismissal / Exits

Diplomatic communication with coworkers is important to the dismissal process. Dismissal needs to come up often and positively in conversation and written communication. In special education there is a business-as-usual flavor, and the topic does not come up much. It is fair to say most educators are ignorant of it. Linda Taylor recounted this story:

“A few months ago, the superintendent of our district stopped to ask how things were going. I said that it had been a good year; that I had just released three students from special education – a 7th grader, a 9th grader, and an 11th grader – and hoped to release more in the Fall. His surprise and shock were clearly evident. Mr. S. said, “Linda, these things never happen! – well almost never! I recently asked a fellow superintendent if he ever heard of any kids getting OUT of special education, and that fellow said that it is very, very rare for that to happen. (That is an accurate assessment.)”

Notions of misidentification and least restrictive environment should be described simply and positively. Gentle reminders and explanations can be worked into routine IEP meetings.

Modeling takes place when a routine exit is proposed. Justification can include why it is necessary to exit children from special education: E.g., “With our speech kids we like to see them “graduate” as quickly as possible so they can spend all their time with their teachers.” Once colleagues understand the process, they tend to follow suit.

Directors of special education differ in their outlooks toward misidentification and some are quite protective of their authority to implement change. Dismissal is not a significant SEA compliance topic. It is something of a taboo to discuss because it implies mistakes and non-compliance. Once dismissal is accepted, directors can be allies for doing the right thing.

The process of advocating for dismissal is the same as advocating for more SLP help. However, it is more rewarding because the result is workload reduction.

10. SLP Dismissal / Exits

A major obstacle to dismissing children from the SLP caseload is the limited development of pupils with moderate-to-severe communication disorders (cf. Dismissal). In every caseload there are children who will never achieve communication competence beyond a functional level. Intervention cannot erase ceilings on learning no matter how long they stay in speech.

Should such children continue to receive services with no consideration for dismissal? No.

A classic example is Down Syndrome clients where overall speech and language development is delayed but follows normal pathways as a function of mental age (an idea proposed by biologist Eric Lenneberg in the 1960s).

Downs clients can be dismissed on the basis of access to the general curriculum. Many, at their functional communication level, can participate verbally in classroom lessons. They can comprehend what teachers say, and their expression is complete enough to be moderately intelligible. They can follow simple verbal directions for classroom activities. Over a period of time they make progress in the general curriculum, usually centering around the acquisition of basic academic skills picked up verbally in the classroom.

Classroom observations can be used to justify dismissal. Is there “sufficient density of verbal stimulation” throughout the day. Is the pupil a verbal participant in the classroom setting – speaking, listening and comprehending verbal transactions? Are verbal transactions more “natural” than the drill and practice routines of direct one-on-one intervention?

Other criteria can be applied flexibly along the lines of those followed by the Sutter Schools (cf. 10. SLP Dismissal / Exits). Meeting essential IEP communication goals can be documented, along with examples showing that direct intervention is not well correlated with speech and language growth. Generalization of learning can be considered. It occurs often that speech and language intervention is “added on” to IEPs, year-after-year, when the general sense is that not much progress is being made.

As children with moderate-to-severe communication problems move through the grades time spent on speech and language skills is better shifted to social and vocational goals. The goal of “perfect speech” is less important than the ability to communicate information for home and work purposes.

Parents need to be coached as to how education is different from training.

9. SLP Dismissal / Exits

Knowing state special education exit criteria as reflections of IDEA 2004 can go a long way to help school speech therapists dismiss children from their caseload and control misidentification.

It is important to appreciate the fact that exit criteria in schools do overlap with those of pre-service clinical training but they are different in critical ways. The chief difference is that a disabled child is evaluated in terms of “progress in the general curriculum.” A child who is able to perform at grade level academically may not be eligibility for special education.

Example: A child who is emotionally disturbed, or appears to be, might be placed in a program for gifted children. The fact that above-average progress in the general curriculum is being made indicates he or she is not a disabled pupil. A similar pattern can arise for autism spectrum children.

Example: A bright male who is difficult to manage in the classroom is not automatically eligibility under Other Health Impairments.

Example: A child who has a mild articulation problem and who is on grade level does not qualify for special education services. Parents can seek therapy off campus. Special education is not a remedial service.

A key test of the PROGRESS-IN-THE-GENERAL-CURRICULUM standard is whether an at-risk child can participate in on-going classroom lessons with peers. If comprehension and production are good enough for the teacher to reach her instructional goals, and performance is at grade level, the child should be dropped from special education.

IDEA 2004 recommends classroom assessments for eligibility determinations. Such information can be used to document progress in the general curriculum.

When a child can participate in classroom lessons, progress in oral speech and language development is supported, especially through literacy instruction. Generalization of learning can move in both directions.

IEP teams do not usually understand the concept of progress in the general curriculum. They need coaching. IEP team members think needs and disability trump general education and least restrictive environment.

8. SLP Dismissal / Exits

The need for speech, occupational and physical therapists to exit children from special education is given weight by the findings of the NOMS project of the American Speech-Language Association. The project presents information on therapy effectiveness for sounds as a function of caseload size [http://www.asha.org/members/research/NOMS/usingdata.htm].

When the caseload is 40 pupils or less, 87.0% make progress; when it is 60 or more, 63% make progress.

When the caseload is 40 or less, 13% make no progress; when it is 60 or more, 35.1% make no progress.

Children who make no progress toward their annual IEP goals cannot be exited because the disability condition remains. At this rate, 13 children yearly will have to remain in special education. After one year, in this hypothetical example, the caseload will be 73 pupils instead of 60.

After years in speech therapy, it might be possible to say the child should be exited because no progress has been demonstrated. However, this outcome might simply be an artifact of insufficient treatment time resulting from a bourgeoning caseload.

As caseloads rise, job satisfaction drops and “burnout” occurs. Because dismissal is a high-level practice skill, new therapists are especially vulnerable to unwittingly escalating their own caseloads and job dissatisfaction. This is the point at which they ask for more help. It is also the point where they can start exiting more children and quickly.

7. SLP Dismissal / Exits

Dismissal patterns vary with school specialties and special education categories (Congressional Report, Nov. 2001, Figure 2).

Speech-language pathology placements are high during the early grades and then drop rapidly after the 5th grade. The drop in the total number of placements by middle school shows SLPs are active in exiting children from their caseloads and doing a nice job. Neglected dismissals tends to occur after the 4th grade. SLPs must continue to monitor their caseloads for dismissal candidates.

Old stone dwelling near stream

Persistent articulation problems are one obstacle to dismissing pupils in the mid-grades. This is a special topic of concern.

Learning disability placements rise quickly at the 4th grade and then decline gradually over time reaching high school. There is relatively less exit activity among special education teachers. Special education teachers do not typically place children in special education and are less likely to propose exits. School psychologists maintain some distance from instruction where they might otherwise identify LD children for dismissal. Special education teachers are not “evaluators” according to IDEA 2004.

SLPs can alert colleagues about the need to dismiss LD pupils in a timely fashion. Exit decisions are team decisions.

Many LD children are also categorized as SLI children. There is a tendency for SLD placements to carry forward SLI placements in the minds of IEP teams.

6. SLP Dismissal / Exits

According to Speechville.Com, “School speech therapists’ caseloads have a tendency to be large. Sixty, seventy, or eighty children per one speech therapist is not uncommon, especially in states that either do not have a legislated maximum caseload limit or the maximum caseload limit provided for by the state’s legislature is very high” (Speechville).

An inventory based on 1999 data is provided for states that have or have not taken steps to limit SLP caseload size. For two states caseload information was unknown. A total of 19 states set no limits.

A total of 29 states did limit SLP caseload size. The range over all was from 40 to 80 pupils. Only three states set limits at 40 pupils per SLP. Twenty-five states maintained loads at 50 or above.

Thus school SLPs have advocated for caseload reductions but only with modest success. They have advocated for more personnel but only with modest success. Loads remain over reasonable limits and SLPs absorb the problem of management and the problem of stress.

Advocating for improved special education eligibility management is an alternative solution to begging for help. It can add status to the role of the professional speech-language pathologist in the school setting where leadership for reducing overidentification is minimal.

SIMPLY — the starting point is to make a list of all the children on the caseload who should be dismissed, and then setting out to make dismissals throughout the school year.   See Managing SLP Exits for an example.

5. SLP Dismissal / Exits

We lack data on speech-language dismissals in schools. Here is one case study example of neglected dismissals.

A speech-language pathologist returned to work in a school district she once served . The special education director approached her and said she must do something about exiting special education pupils from the high school. She gained the impression there had been quite an accumulation.

One of the older pupils whose records she reviewed had been her client in the first grade. In fact she had established eligibility on the basis of a diagnosing an auditory processing problem. Now she found him still enrolled the high school special education program. The mother had to be convinced of the need to exit the young man. Required was retesting for auditory processing abilities. The signs were negative and the young man was dismissed.

In all, the SLP dismissed some 25 pupils from the high school. A review of records indicated IEP teams had simply renewed IEPs yearly without regard for disability re-evaluation. The pupils were “passed on” so to speak.

It is likely that some of the children never had disabilities in the first place. They were “re-misidentified” year after year while carrying the stigma of special education placement. A proactive special education director made the difference.

The thoughts of Linda Schrock Taylor come back into focus:

“Every year, thousands of our children disappear into the vagueness of special placements, never to be released from the labels and stigma; never to escape and again be seen as ‘normal.’ Many teachers must notice this engulfing, this entrapment, of our children; some teachers must surely strive to defeat this grave and senseless closure on potential; but the problem is rarely mentioned or discussed” (Linda Schrock Taylor).

4. SLP Dismissal / Exits

The overriding factor making special education dismissal difficult is an historic bias favoring Most Restrictive Environment (MRE), not Least. MRE is placing an at-risk children in education situations that continues to impose limits on a full range of opportunity to learn the way non-disabled children learn. The bias is segregation of the handicapped and it affects non-disabled children who are hard-to-teach.

At the beginning of the 20th century handicapped persons were segregated and excluded from schools (cf. History of Misidentification). For those who did attend they were often misidentified as mentally retarded and placed in isolated self-contained classrooms and buildings.

Parent advocacy groups winning court concessions cleared the way for FAPE in IDEA 1997. The issue was civil rights, not theories of education.

As handicapped children poured into schools, special education placement became the new way of segregating children. Mental retardation as the category of choice was replaced by “specific learning disability.” That category grew 300%. Hard-to-teach black, poor, language-different, hyperactive, male, emotionally challenged and native American children were segregated from general education programs by strict regulations and cumbersome paperwork.

General educators did little to develop strong remedial programs to prevent overidentification (e.g., response to intervention). Remedial education was shifted to special education. Professional organizations advocated for hiring more personnel to serve the many children who were incorrectly placed in special education. The point was reached where Congress had to address “disproportionality” as in IDEA 2004. There was no evidence whatsoever schools were self-correcting for the problems of misidentification.

Parent advocacy deflected children into special education. Schools were typically mute about the risks of special education, and parent and legal organizations continued to behave as though it were 1940. Parent fears and teacher convenience did much to keep children in special education when the objective results were negative.

The negative effects of long-term MRE placements were demonstrated by graduation failure rates. Many at-risk children got stuck in skill development paradigms through the middle school years only to reach a point where they were ill-prepared to deal with the social-communication and vocational issues of high school (cf. 6. SLP Caseloads). Many “graduated” into community placements that continued to segregate people from communities.

Least Restrictive Environment places a responsibility on IEP teams to WEIGH the risks of special education placement and retention. Across America’s schools IEP teams prefer the risks of stigmatizing children’s academic careers to the risks of school non-compliance and inconvenience.

School psychologists, speech-language pathologists, recreational therapists, physical therapists, special education teachers, occupational therapists, reading specialists, special education directors, and behavioral therapists need to improve their skills to exit children appropriately from special education and integrate them into general education.