Monthly Archives: March 2010

SLP Caseload Management

Seen through search records the topic of how SLPs handle their school caseloads continues to be a significant topic. If there is one issue that binds us together, it is the high demands placed on us to take care of all the pupils who come to us.

Aggregate Data

We continue to argue that one must manage the total caseload and not only individual children as described on IEPs.  We individualize, yes, but to see the “big picture” one must use aggregate data breaking down the caseload into types of children served.  This is important to see patterns of special education admission and dismissal.  It is evident non-disabled minority children make up a part of almost all caseloads and should be dismissed. 

Girl Scouts Marching on Main Street.

Every case dismissed is one less to contribute to “burnout!” 

SLI Placement

We can APPLY our backgrounds in cultural variation and testing procedures to reduce the number of children we recommend for placement in special education.  This cuts down on our caseload size.  We are in control.

SLI Dismissal

We can APPLY our backgrounds in cultural variation and testing procedures to dismiss children from our caseloads who do not belong there.  This cuts down on our caseload size.  We are in control.

Collaboration

We can join and promote programs such as Response to Intervention to reduce the number of children placed in special education.  This cuts down on our caseload size.  We are in control.

End Result

We can review our caseloads and make sure only qualified children are in them.  We can keep our eye on the target:  Good case management leading to high school graduation and post-secondary success. 

We are in control.  We don’t need to wait for the state to hire more speech pathologists for our school.

29. Causes: IEP Teams

Among school special education personnel, support staff and involved parents in the nation’s 100,000 schools, it is hard to discern WHO actually decides to misplace at-risk children in special education programs.

Those who have worked in schools know there is a hustle-bustle to the day. Everything has to be done pronto, or literally the system will fall apart. Or so it is thought! “There is so little time to think.”

The remarkable thing about special education IEP teams is that they seem to know what to do but they do not understand false identification.

IEP teams have a profound trust in the notion that somebody knows what’s right. After all, they have the paperwork to fill out. Yet we know local, state and federal specialists, experts and lawmakers feel powerless! Everyone else is causing problems.

Almost everyone says there isn’t enough money to make education right. “If only we had enough money!”

So we can say that decisions to misplace children in special education programs arise from hundreds of programmatic, financial and regulatory defaults overriding the good judgment of smart people in fine communities. We are left with the “culture of compliance.”

Defaults are not exclusive to education, however.

We stress the work of Jack Wennberg. In the 1970s “…he had compiled data about health care practices in cities all over the state of Maine, including data showing that in the city of Lewiston, an unusually large number of women were having hysterectomies. He projected that if the rate of surgeries continued in Lewiston, 70 percent of its women would have a hysterectomy by age 70” (NPR Health). Well educated medical doctors can drift far away from their foundations when they practice in ordinary communities.

By the time knowledge trickles down to the local level, it is folded into social structures that distort that knowledge, sometimes to the point where there almost no knowledge left to counteract local beliefs and conveniences.

Too Many Children in Special Education!

Too many American school children are placed in special education. Once there were handicapped children who did not attend school, and those who did did not receive a “Free Appropriate Public Education.” In 1975 at the time of enactment of Public Law 94-142 (Education of All Handicapped Children Act) too few children received proper special education. Special needs children were under served. But subsequently their numbers rose rapidly:

“Special education enrollments grew dramatically after the federal special education law went into effect in 1976 (sic). Then, 8% of all public school students were classified as having a disability. By 1990 it was just under 11%. The growth accelerated throughout the 1990s, and by 2000 it was over 13%. The growth seems to have tapered off in the early 2000s, but the over 50% increase in the percentage of students called “disabled” remains” (Foster and Greene, 2008).

Why? Jay Green says growth cannot be attributed to disability factors:

“The number of premies and deinstitutionalized students pales in comparison to the growth in special ed, which has almost entirely occurred in SLD.  And mental retardation has been declining and total severe disabilities have remained flat over time, contrary to what one would expect if premies and deinstitutionalization were at work.  And poverty cannot, by definition, be the cause of a disability.”

The National Education Association looks at the numbers problem this way: “Over the past 10 years, the number of U.S. students enrolled in special education programs has risen 30 percent. Three out of every four students with disabilities spend part or all of their school day in a general education classroom. In turn, nearly every general education classroom across the country includes students with disabilities. Each school and school district must determine the best way to conduct programs and figure out how to pay for them.”

Steppling, Quattlebaum and Brady (2008) report the same trends in school speech-language pathology: “The number of children receiving speech–language therapy in the schools has been increasing. Information from the American Speech-Language-Hearing Association (ASHA) indicates that between the 1991–1992 and 2000–2001 school years, the number of children being served by speech–language pathologists (SLPs) grew by 9.5% (ASHA, 2004). “SLPs are increasing their rates of placement commensurate with national trends. Along with school psychologists, speech-language pathologists have been placing the majority of added pupils to special education.

8. SLP CASELOAD CUTS

Let’s talk about practical techniques for reducing the SLP caseload by way of Strategic Eligibility Management – practical points.

OVER-IDENTIFICATION

First, assume you are placing too many children in special education.

National statistics and trends suggest SLPs are a part of the problem, especially with respect to phonology, language and learning disability where there is a lot of judgment involved.

Second, go over No Child Left Behind procedures in your school.

This is an old act going back to the civil rights era of the 1960s designed to help “struggling students.” Some schools will have some kind of child study program and pre-intervention planning. Plan to make use of it.

Third, push back on teacher referrals.

See if you can get the pre-intervention committee to meet and organize concrete suggestions for referring teachers. Participate and suggest techniques. Stress that pupils must be showing academic difficulties to be placed in special education. Try to prevent hasty referrals to special education, which require legal response within 60 days. Here is where the placement expectation gets set up because a referral is formal.

Fourth, promote a preschool intervention program to reduce referrals and placements.

Someone’s got to do it! It is hard to see that the 100,000 American schools are making rapid progress in this area. States cut out preschool programs. Check with your state requirements for preschool placement. Obviously functional articulation cases are suspect.

Fifth, flat out be on guard about admitting minority children, especially those with limited English.

Watch out for boys from minority groups. They have double jeopardy because they are boys. Watch out for the “hard to teach.” Watch out for emotional disturbed and hyperactive children. Most schools do not know what to do with “struggling students” and they tend to stick them in special education for remedial help.

Sixth, don’t misinterpret standardized test results for minority children. School psychologists have been doing this for a long time, to the point where IDEA 2004 knocked back reliance on standardized tests, and promoted wide arrays of evidence-based assessments.

7. SLP CASELOAD CUTS

Let’s talk about practical techniques for reducing the SLP caseload by way of Strategic Eligibility Management – practical points.

DISMISSAL PROCEDURES

First, make a list of what has to be done to dismiss a pupil from speech.

We say it is four times harder than determination. Not necessarily in time spent but in the number of criteria that have to be met. There are data forms for current levels of performance. Current goals must be closed out to a reasonable degree. Parents will need to be notified. The IEP team will need ample justification.

Second, make sure you understand the IDEA criterion of progress in the general curriculum.

There can be residual speech and language deficits that do not affect access to the general curriculum. Plan to exit these children. Identify SLPs in the community who can provide private therapy.

Third, some children can exit with intensive direct intervention to overcome stagnant goals.

Give goals attention early so you can exit children sooner. Exiting articulation problems is different from dropping service for an autistic child whose symptoms include pragmatic deficits. A pragmatic deficit might not affect participation in classroom lessons, or it might just be a symptom of the disorder.

Fourth, communicate freely about exit pupils.

Notify the office if the exit procedures require additional paperwork. Communicate with teachers and parents. In sending home quarterly progress reports, mention an exit is planned soon because of good progress. Pupils should “graduate” from special education positively.

6. SLP CASELOAD CUTS

Let’s talk about practical techniques for reducing the SLP caseload by way of Strategic Eligibility Management – practical points.

LISTS

First, make a master list of your 50 cases and study it.

We think of SLI children individually and clinically but using aggregate data reveals trends. Use a spread-sheet on your computer if possible. Columns can be labeled and sorted. Tally subtypes. Recode to create consistent groupings of interest.

Second, look for patterns.

Time in special education? How severe? Males? Transfers? Types of disorders? Minority children? Second language learners? Dual classifications? Missing types like TBI? Consults, collaborations and direct service? Look for patterns of misidentification, over-identification and under-identification.

Third, list the children who should be exited.

Some for sure will not exit. Think of why that is. Others will be possible exits. Think about how goals can be reached and closed out to justify dismissals. Other children will be clear cut cases, such as mild articulation problems.

Fourth, identify children whose placements are too restrictive.

Plan to reduce direct service time and increase consultation. Plan to move some children into groups. Where possible, seek collaboration with teachers and therapists. It will be wise to communicate your intention to exit children who require less direct service.

Fifth, try to anticipate new arrivals in the spring.

If you work in a middle school, for example, check with your SLP staff to see who is moving into your caseload. Ask which ones should be exited soon and add them to your list. Look to see how your colleagues handle dismissals and eligibility determinations.

5. SLP CASELOAD CUTS

Let’s talk about practical techniques for reducing the SLP caseload by way of Strategic Eligibility Management – practical points.

ETHICS

First, understand that school ethics are different.

Special education personnel are governed by federal and state statutory law. That law stems from the U. S. Constitution and various civil rights findings. SLPs must not place non-disabled children for speech and language problems. They must not let clients languish in special education without continuing evidence to support continued placement.

Second, clinical ethics and FAPE ethics are different.

From 1997 to now, the “progress in the general curriculum” may override clinical standards for therapy progress. An exit from special education may or may not correspond to an exit rendered in private practice. A speech and language problem does not automatically make a pupil eligibility for special education.

Third, evidence-based practice raises ethical questions.

Suppose we find that collaborative preschool intervention emphasizing reading in relation to speech deficits reduces the number of SLI children placed in special education. This raises the question of SLP method selection for educational purposes. Isn’t conventional one-on-one treatment called into question as an ethical choice?

4. SLP CASELOAD CUTS

Let’s talk about practical techniques for reducing the SLP caseload by way of Strategic Eligibility Management – practical points.

SET A GOAL!

First, start the new school year with a goal of 10% reduction in caseload through SEM.

Even if you fail entirely the goal will force you to question your overall judgment about how you evaluate children, how you handle least restrictive environment, and how you dismiss children. You will be surprised that once you set the goal, there is a lot to learn. It is a different way of thinking about “service.” You service your children well when your eligibility determinations are correct! Getting kids out of special education is a service, too.

Second, announce your goal informally and informally.

Perhaps the director of special education has a personnel process you can use covering goal setting for your employment year. Explain your goal and give him or her something to read about over-identification. Tell other SLPs your caseload is big and now you are going to try a fresh approach, disqualifying more children from speech services. Or, say, “I’m going to try to do more consult work this year.” Get the word out that you are taking a fresh look at caseload management.

Third, consider that a small reduction in caseload size helps you a lot improve service to other children who really need you.

If you have 50 children to start off with, you will end up with 45 at the end of the year. This is a significant workload reduction. If you exit one hard case, it will be like exiting two children. After some success the first year, it will go much better the second. In fact, you may wonder why it took you so long to see caseload management as service delivery.

3. SLP CASELOAD CUTS

Let’s talk about practical techniques for reducing the SLP caseload by way of Strategic Eligibility Management – practical points.

CHANGE YOUR ATTITUDE

First, believe you have children in your caseload who shouldn’t be there!

Be sure to listen to your own excuses to see if they are valid. Often they revolve around perfectionism. Some children will just have to go into life with imperfect /r/s, limited vocabulary, short sentences or mild dysfluency. Get used to the idea you can’t solve every problem.

Second, weigh stigmatization against benefits.

This is “big picture” thinking! What are the long-term needs of the children in the speech and language caseload? To have a vocation one day? To be accepted for who they are no matter what their disability?

Third, be prepared to “rock the boat.”

Not everyone will agree with your exit recommendations. Be prepared to make mistakes according to what the IEP team says. Parents often for good reasons will advocate for their children continuing on in special education. You might embarrass some co-workers.

Fourth, over-prepare to make sure your evidence is strong.

A clown on mainstreet.

Be prepared to explain your point of view and give justifications.

Somehow you have to explain the problem of “over-identification” to some colleagues who may be biased for it.

Fifth, accept limited success, especially the first year.

SLPs have a good track record of exiting mild articulation problems but they are not as strong exiting pupils with mild-to-moderate problems. Accept an exit success rate of 75%. For placements, SLPs have a record of placing too many children. Accept a placement reduction rate of 25%.

Fifth, really apply the information you memorized in graduate school.

You know about cultural and linguistic differences because you studied them! You were told about the short-comings of norm-referenced tests. Don’t just sit at IEP meetings and nod your head when you know better. SLPs are placing a lot of non-disabled minority children nationwide because they don’t understand and apply what they memorized in school.

Sixth, get used to the idea that all school personnel tend to over-identify at-risk children for special education, and this includes SLPs.

Read up on the problem and become objective!

4. SLP Collaboration

In 2002, now eight years ago, the President’s Commission on Excellence in Special Education made this comment about the problem of the preventing special education over-identification:

“The Commission finds that the IDEA establishes complex requirements that are difficult to effectively implement at the state and local level. Nowhere in IDEA is this more complex than in the eligibility determination process. Improving this process, coupled with research-based early intervention programs, may reduce the number of children who are identified as having a disability, particularly when early identification and intervention are in place and research-based interventions are provided before referral” (Commission).

The Commission recommended improving the “eligibility determination process” saying it “…may reduce the number of children who are identified as having a disability…” Suggested was the solution of “research-based early intervention programs.”

Key here is that U. S. school SLPs are partners in improving the eligibility process. Our posts recommend “Strategic Eligibility Management.” Part of the solution must be reached through collaboration. Programs should be started by SLPs to provide school leadership. Collaboration should be a skill learned in college practicum prior to school employment. Educational speech pathology is too important to leave to on-the-job training.

There is moderate evidence that response to intervention and similar prevention programs are being implemented long-term in U. S. schools. There are models, pilot programs, and scattered efforts, but protracted development is surprisingly uneven even though hopes ran high after the authorizations of IDEA in 2004.

SLPs must step forward and help to reduce the over-identification of at-risk children. They must see it as AN ETHICAL PROBLEM. They must move away from pull out services and begin to manage their caseloads with a broader perspective. They can also help themselves reduce caseload demands.