Managing the Impact of Market-Driven Changes in Communication Sciences and Disorders in Educational Settings

Nancy P. Huffman,  M.S.
Consultant in Education Based Speech-Language and Audiology Services

The Past Quarter Century

When today's futurists become tomorrow's historians, they will most likely view the past quarter century as a mere blip.  But what a blip it was for individuals with disabilities in terms of education and special education in this country. The seeds of change were planted in 1973 with the Rehabilitation Act, Section 504.  Programs receiving Federal funds were targeted which meant that individuals with disabilities were to be provided accessibility to public education.  Frankly, public schools didn't pay too much attention to this mandate.  They did, however, pay attention to the landmark legislation of 1975, Education of All Handicapped Children Act, which made school districts responsible to provide a Free and Appropriate Public Education (FAPE) to students with disabilities residing in their district. For the first time, school districts were required to engage in Child Find, evaluation, placement and monitoring of disabled students, a major challenge.

While the special education community was enjoying inroads gained through PL 99-142, the nation's public had growing concerns about the status of education in general.  This concern came to a head in 1983, with the publication of A Nation at Risk (National Commission on Excellence in Education, April 1983).  All of education in the US was severely criticized for failure to produce students who could function in society, failure of curricula to prepare students for the work place, high drop out rates,  and a lack of nation-wide standards in comparison to other countries.

Eleven years after its passage, PL 94-142 was amended in 1986 by PL 99-457,  the Education of the Handicapped Amendments.  The rights and protection of children with disabilities were extended by mandating services for those ages 3-21 years,  and by creating incentives for states to identify lead agencies to develop Early Intervention (Birth -3) programs.  However, with this expansion of special education services came a message of concern from then Assistant Secretary, US Office of Special Education and Rehabilitation Services (OSERS), Madeline Will.  Suggesting that we inadvertently created a barrier to successful education of children with disabilities through the "pull-out approach," she called for a partnership between general and special education (today a legislated reality) known as the Regular Education Initiative (REI) (Will, 1986).

In 1989, US Governors held an education summit and laid the ground  work for education reform.  A National Education Goals panel was established to address six goals summarized as follows:  All children will start school ready to learn; high school graduation rate will be increased to 90%; American students will leave grades 4, 8, and 12 having demonstrated competency in challenging subject matter including English, math, science, history and geography;  American students will be the first in the world in math and science; every adult American will be literate and will possess knowledge and skills to compete in a global economy and exercise rights of citizenship;  every school in America will be free of drugs and violence and will offer a disciplined environment conducive to learning.

The year 1990 marked the reauthorization of PL 99-142 as the Individuals with Disabilities Education Act (IDEA).  Its renaming reflected a change in attitude, recognizing that people with disabilities were not necessarily "handicapped".  Further, in changing the word order, people with disabilities were first, "individuals" and second, with a "disability."  The IDEA placed renewed focus on Free and Appropriate Public Education (FAPE) in the Least Restrictive Environment (LRE) and required states to defend "pull-away services" in their federal compliance reviews.

The year  1990 was a landmark year for all individuals with disabilities, for this was the year that the Americans with Disabilities Act (ADA) was passed.  This legislation assured the rights of individuals with disabilities to have access to employment, public services and programs, and places of accommodations beyond just those places and programs receiving federal funding as was mandated in Section 504.

In the early 1990's education reform was underway in most states.  Reform focused on outcomes for students rather than focus on process.  This change accommodated, in philosophy, the needs for students with disabilities.  In 1994, the Goals 2000:  Educate America Act (PL 103-227), created funding and codified the original six National Goals developed in 1989. Two new goals were added; addressing teacher access to professional development and increased parent involvement in promoting social, emotional, and academic growth of children.  Not to be left out, the disabilities community developed and published the National Agenda for Achieving Better Results for Children and Youth with Disabilities, thus assuring the inclusion of children with disabilities in the overall plan to meet the Goals 2000 initiatives.

 At about this same time, our professions responded to forces and information impacting speech-language pathology and audiology as professions.  First, was the realization that between 1984  and 1994 enrollment in managed care had doubled (Frattalli, 1998),  going from 21% of the population in 1984, to close to 45% in 1994.  ASHA became acutely aware that if managed care funded a defined set of services to a defined population, then it needed data to demonstrate why we do what we do, to show how long it takes, and to show our clients pre-service status vs. end of service status.  We need the outcome data to show that our services are valuable and worth reimbursing.  Second, was the Pew Health Commission's report in 1995, calling for greater efficiency in the education of health care professionals (i.e., reduced duration and cost) and the development of multi-skilled, cross trained, multifunctional professionals (school practice was ahead of its time with regard to this).  The report challenged licensure, certification, and accreditation saying these processes created multilayers of rules which only created barriers rather than opening doors for employers and consumers  (O'Neil, 1993).

Just three years ago, in 1997, IDEA was amended. Its reauthorization focused on the next step in Least Restrictive Environment, the access of children with disabilities to general education.  The premise being that special education is a service and not a place.  After considerable input from many sources, including ASHA, IDEA regulations were published in March, 1999, to take effect in May, 1999.

The year 2000 is the Silver Anniversary of IDEA.  In 25 years we have come a long way and we should congratulate ourselves.  Attitudes have changed with regard to disability vs. handicapped.  We changed where students with disabilities go to school. We've changed emphasis from where special education occurs to how it occurs.  But, for those familiar with Spencer Johnson's book (1998), Who Moved My Cheese, the cheese has moved! We have new challenges and opportunities. In facing these challenges and opportunities, are we "Hem"? "Haw"? "Sniff" or "Scurry"?

The Present: Forces Influencing Schools Practice Today

Today, I will review six areas having major influence on the practice of speech-language pathology and audiology in educational settings.

1. Legislation and Regulation

At the Federal level, IDEA guides what we do with students who qualify as disabled.  The key operative phrase throughout the new regulations is "general education curriculum."   It permeates eligibility, evaluation,  IEP content, IEP team, and student performance.  Key areas of interest for speech-language pathology and audiology include:

Assistive Technology (§300.346) .  Assistive technology must be considered in the development of an IEP for any child who is classified as disabled.  Assistive technology can be taken home on a case-by-case basis.  (§300.308) Teachers and others must be trained in the use of the student's assistive technology.  (§300.6)  A student's assistive technology must integrate with technology used in general education.

State-wide and District-wide Assessment (§300.138).  In state-wide and district-wide assessments, students with disabilities must be accommodated and participate in state and district assessments.  Performance of students with disabilities must be included in reporting of performance of all students.  Alternative assessments for students with disabilities must be in place by 7/2000 for those students with disabilities who cannot participate in state and district assessments.

Evaluation (§§300.530-300.536) .  Student evaluations must provide answers to the following questions:  Does the child have a disability?  What are the present levels of performance and need?   Does the child need special education and related service to participate in the general curriculum?   Characteristics of standardized tests used in evaluation are spelled out. (§300.532)

The evaluation requires a variety of assessment tools and strategies including parental information and information related to involvement and progress in general education (§300.532).

IEP Team (§300.344).  The IEP team includes the child's regular education teacher, the child's parent, a school representative knowledgeable about general education curriculum, a person who can interpret instructional implication of evaluation results.  The IEP team may include a person with "special expertise" identified by either the parent and/or the school.

IEP Development (§300.346).  The IEP team must consider three general factors:

The IEP team must consider five specific factors: Least Restrictive Environment (§§ 300.550 - 300.556).  Students with disabilities are to be educated to the maximum extent appropriate with non-disabled peers .  Students with disabilities shall participate in regular education environment.

Functional Behavior Assessment (§300.520).  Functional behavior assessment requires behavior assessments and the development of behavioral intervention plans for students in need.

At the state level, most states are restructuring general and special education. Many have developed learning standards for all students.  Most are incorporating state and district-wide assessment for all students including students with disabilities.

Given the changes in Federal and State regulatory requirements, we must be able to define and measure outcomes, demonstrate our effectiveness, and we must accomplish more student progress in less time.  That means we must be able to analyze general curricular goals and design IEPs that focus on student success in meeting general education requirements.  The speech-language pathologist must:
 

In summary  then, we must be able to define and measure outcomes to demonstrate our effectiveness. We must accomplish more student progress in less time.

2. Demographics

Let's look at the demographics of students being served in schools today and how this influences practice.

Who comes to school?  In any school classroom today one might expect to see one or more students representing any one of the thirteen disability classification:  autism, traumatic brain injury, emotional disturbance, speech or language impairment, multiple disabilities, specific learning disability, other health impaired, speech or language impairment, etc.  Students having these classifications might also be medically fragile, technologically dependent, dealing with dysphagia, fluency difficulties, phonological disorders, genetic disorders, etc.  They  may be non-English speakers, or Limited English speakers.  They may be non-verbal.

Classrooms of course, contain students who are not classified as disabled under IDEA.  These could be students considered disability-free.  There may be students with mild disabilities; students with and without communication difficulties; students with 504 plans.  Or, if in a private school, a student with a "services plan."

Along with this diverse group of students comes a classroom staff, including one, maybe two, teachers, classroom aides or paraeducators;  1:1 aides assigned to a child; perhaps a nurse; and a cadre of related services providers desiring to provide individual-specific services in push-in or pull-out fashion.

Who comes to school is a direct result of forces in general education.  This includes pressure on school districts to reduce the numbers of students identified with disabilities, and pressure to address over-representation of minorities in children classified as disabled.  There is also an increased number of requests for 504 service plans, LRE (Least Restrictive Environment), and FAPE (Free and Appropriate Public Education) initiatives.  As stated earlier, the focus of IDEA is on the participation of students with disabilities in general education.  Further, the prevailing attitude that children with disabilities need to grow up and be educated in their own villages is resulting in a reduction in out-of-district placements. Advocacy is a factor in who comes to school.  There are strong parent networks with many groups insisting on inclusionary educational programs and experiences.  Funding initiatives is a factor in who comes to school.   As will be discussed later, states are rewarding schools through increased financial aid for those who service students with disabilities in general education.   General education placement as first choice. Some parents do not wish to have their children "classified."

Understanding the Disability.  Knowing the composition of today's classroom and instructional settings, speech-language pathologists and audiologists in education must understand the disability.  As stated before, overall knowledge of general characteristics and typical education intervention for each disability is pre-requisite to the treatment of the communication disorder associated with the disability.  We must use intervention and therapeutic techniques to treat the speech, language, fluency, voice and swallowing disorders that present themselves in the educational context.  Specifically, we must be able to document how these disorders adversely affect educational performance and success within the general education curriculum.  We must also be skilled in working with others to develop a student's medical plan and carry out its requirements.  Speech-language pathologists must evaluate and select appropriate treatment protocols.  Following principles of evidenced-based practice we must use treatment procedures based on data published in peer-reviewed journals that have been proven based on clinical trials, and have shown to be effective for particular populations or disorders (Logemann, 2000).  We need to be more skilled in evaluating novel/alternative therapies and have the knowledge and confidence to state which procedures have efficacy (documentation that it works) and which procedures have no evidence of efficacy.  We also need to have sensitive understanding as to why schools become involved in providing services and interventions that have not been proven.  We also must provide communication treatment and intervention strategies that result in progress in the general curriculum.  We cannot lose sight of the fact that the purpose of our therapeutic intervention is to afford a student's progress in education.

3. Service Delivery Issues

We continue to be quite comfortable in the clinical model of service delivery which typically translates to a "pull-out" approach.  Our students in their clinical preparation have the most experience in this model.  Many speech-language pathologists engage in educational service delivery models called collaborative consultation, "push-in," classroom-based, integrated, and community-based models to name a few.  Probably, most use a blended model that might include "pull-out" for specific skills development, drill and practice, in conjunction with a classroom based component to integrate and generalize skills into the curricular instruction.

Today's speech-language pathologist must be prepared to function in an array of service delivery relationships, ranging from the solo therapeutic/teaching model to co-teaching models.  In pursuing co-teaching roles, we might look to the education literature dealing with co-teaching roles so that we can be familiar with descriptors and techniques such as "speak and add," "shadow,"  "parallel,"  and "lead and support" roles.  In recognizing the constraints and opportunities of the solo therapeutic approach, we must recognize that the pressure is on us to not remove students from the classroom and that the therapeutic "drill and practice" must be directly connected to a skill used in general education.

Given the pressures of service delivery, speech-language pathologists working in education settings today must be able to effectively select and dismiss students from their caseload.  We have to determine who is eligible for services and who is not.  We  desperately need our NOMS data to assist us in determining the prime time for intervention for certain disorders, appropriate level of service in terms of frequency and intensity need for individual vs. group, how many sessions are necessary, how much progress to expect in the course of an academic year, which service delivery model to use, what to treat first, and when to dismiss.

We need to promote dismissal as a positive outcome.  Shouldn't we be promoting increased independence rather than continued dependence on our service?  Often we are so focused on securing services that, once in place, we lose sight of the need to reduce and end services.

We need to recognize that teachers are part of the "caseload."  When we persist in only counting students as caseload we forget a most important client,  the teacher.

We need to effectively manage large caseloads.  What is appropriate caseload size?  I'm not sure we know the answer to that question. Depending on a number of variables a caseload of 10 -15 may be maximum for one speech-language pathologist, while a caseload of 70 could be a comfortable maximum for another.  The 1999 ASHA Omnibus Survey provides caseload information based on the  number of different patients served in a typical month by speech-language pathologists in various work settings.  These data are shown below:

Mean number of different patients served in a typical month:
 All speech-language pathologist respondents = 42
 School speech-language pathologists  = 50
 Hospital speech-language pathologists  = 42

It should be noted that there was no caseload information reported for private practitioners.  Are the mean caseload sizes excessive?  Are they significantly different among school settings and hospital settings?  How do classroom based services get counted?   Do we attempt to compare apples and oranges when we look at caseload size?

Hopefully we can become more skillful in looking at systems management approaches to caseload management.  For example, IEPs are capable of being changed at anytime.  Students can move in and out of caseloads very easily, especially if they are not classified.  Should we consider a continuum of service from most intensive to least intensive and develop service plans accordingly?

4.  Personnel

In the school setting we work with parents, regular educators, teams, paraprofessionals, supervisors and administrators.  The beneficiary of our collective effort is the student.  The school employer expects personnel to work collaboratively, have content and technical knowledge, design/deliver treatment to support instruction, assess students based on learning standards of the district and the state, guide, and direct others who function as support to instruction.

Speech-language pathologists and audiologists need workplace skills that allow us to work hand-in-hand with the regular educator, to serve as case manager, to design services in a team context, to provide direction and guidance to paraprofessionals, aides, and parent volunteers, to supervise and be supervised, and to engage in self-generated professional development

5. Workforce

The reauthorized IDEA and its regulations introduce the use of paraprofessionals (§300.382).  States are given the options to use paraprofessionals in the provision of special education.  IDEA wants states to ensure personnel are available to provide special education and related services.  States are required to more accurately project vacancies and shortages.  Is there an overproduction or a shortage of speech-language pathologists?   Is there an overproduction or a shortage of teachers?  Recall, that in many states, speech-language pathologists who work in schools must also be certified as teachers.

The ASHA Workforce Study (Vector Research, 1999) projects an oversupply of speech-language pathologists that will peak in 2012.  The study points out, however, that in 1997, there was a relative balance overall, between supply and demand of speech-language pathologists.  However, when looking at employment settings, there was a shortage of SLPs in the education setting. With the more recent reduction of speech-language pathologists in residential care settings, the education setting is benefiting.

In New York State (New York State Education Department, 1999), where there is a shortage of speech-language pathologists certified to work in school settings, ten universities have been awarded a one-time Intensive Teacher Training Program grant to prepare licensed and ASHA certified speech-language pathologists to meet teacher certification requirements.  Content requirements of the course are:

(1)  Knowledge of laws and regulations as they apply to practice in the schools, covering legal bases for services in schools including state regulations for classification and placement of a student with a disability; unions and contractual agreements; and the structure of education.

(2)  Knowledge of the implementation and provision of speech-language services within the public school curriculum, including integration of language instruction in the school; assessment procedures related to competence in a grade level curriculum; using curriculum content in therapeutic planning; modification of curriculum; and principles of early learning and literacy.

(3)  Knowledge of instruction planning, teaching methods and models including service delivery in instructional settings; classroom behavior management; planning for diverse populations and learning styles.

(4)  Ability to work effectively within a school system, including working on teams; effective communication skills; and positive advocacy for school-based speech-language pathology and audiology services.

(5)  Knowledge of supervisory responsibilities and administrative procedures necessary to provide effective support and information to candidates for state licensure/certification including  supervisory relationships and roles, contractually agreed upon procedures for performance, and professional growth plans.

(6)  Knowledge of assistive and educational technology resources including general use of technology to enhance communication in general education, and adapting technology for classroom use.

Given the workforce skills required for schools practice, speech-language pathologists of today must be able to demonstrate knowledge of laws and regulations that apply to the school setting.  The speech-language pathologist must be able to  recognize who the decision-makers are and how to work cooperatively with them;  evaluate students in the educational context; choose assessment tools providing data that can be connected to a student's potential for success in grade level curricula; implement curriculum modifications at every grade level; plan instruction with sensitivity to diversity and exceptionality; design treatment plans that support classroom curriculum; and participate in planning and carrying out behavior management procedures.  (A key role if we view behavior as communication being acted out.)

6.  Funding and Reimbursement

It is no secret that IDEA funds are not flowing as promised.  When enacted in 1975, federal funding was anticipated to cover up to 40% of program costs.   However, today the federal government funds approximately 13% of the cost of IDEA.  Thus, states and local school districts fund the balance.  School districts must, therefore, increasingly rely on the local tax base to support the rising costs of special education.  Included in this are costs associated with what some districts view as excessive amounts of various therapies on an IEP.  Also included are increased litigation costs as district decisions, or parent requests, are challenged and clarification is sought through administrative hearings or court decisions.

Schools are increasingly accessing Medicaid reimbursement for certain related services provided in schools.  At the state level interagency agreements have been established to allow for this.   As a result, speech-language pathologists and audiologists in school settings have much the same paperwork and documentation requirements as do professionals in health care settings.

In terms of managed care, insurance companies are refusing to cover services if they are available in schools.  Thus, placement committees and related services staff must accommodate, as well as work cooperatively, with insurance companies to resolve issues that arise.

Finally, there are state driven initiatives to promote participation of students with disabilities in general education curriculum.  For example the New York State Education Department (1999) has created additional weighting in the state aid formula so that school districts can receive additional funding for the education of students with disabilities.  In order to qualify, students with disabilities must be receiving special education services in the general education classroom for 60% of the school day.  Pull-out related services, pull-out resource room, and segregated special class services do not qualify. Related services in the general education classroom do qualify.

Given funding and reimbursement requirements for their services, speech-language pathologists and audiologists in school settings must be better able to handle large caseloads using a systems approach, use data collection instruments which satisfy reimbursement requirements, and use service delivery models that satisfy reimbursement requirements in terms of a school district's state aid.

The Future: Opportunities for Change

While 50% of our workforce is in school practice, the practice issues they face are quite similar to those faced in health care and other practice arenas. In preparing for professional practice, I do not advocate for the creation of new courses.  Rather I challenge us to look at how we deliver our current instruction.  Some adjustments in educational preparation I would ask us to explore are the following:

Study the impact legislation and regulations have on education.

Legislation and regulation dictates what is done in schools.  It dictates what is done in health.  It dictates what is done in almost every employment setting in which we find ourselves.  Let's consider increasing the depth of instruction in legislation and regulation and its influence on practice.

Adjust instruction on assessment and evaluation so our students can take it to the next level.

 Help our students take assessment beyond the normal vs. non-normal development, disordered vs. non-disordered framework, with which we are so comfortable, to the concept of "in relation to what."  In education, our assessment should be the students success in the curriculum  In health care it might be living at home, or adjusting to job requirements.  When we identify a disordered skill we need to ask ourselves "so what?"  What does the lack of a particular skill mean in this student's/person's circumstance.  When we present evaluation data today, "So What," "In Relation To What," are the questions we are asked daily by placement committees (and MCO's) as we attempt to justify services.  "How does lack of that skill impact success in math, reading, social studies, etc.?"   Incorporate the notion of evidence based practice principles into all instruction.  On what basis do we choose protocols and interventions?   How to we apply evidence based practice principles in daily clinical practice?  How do we create learning experiences which involve data collection practices relative to client outcomes.   In our clinic experiences, we need to help students  identify an appropriate outcome and then collect data to trace their steps to achieving that outcome.  As part of identifying outcomes, we should connect with schools to set outcomes that are functional and relate to curricular success.  We should create learning experiences that develop workplace skills and group assignments that involve teamwork to help students recognize that teams form, storm, norm and perform; that teams prioritize; that teams must resolve conflict; and that teams must work as a unit.  Group assignments might also be developed through connections with other departments such as occupational therapy, physical therapy, special education, and regular education.  Our instruction should provide content knowledge in general education curriculum.  Assignments involving curriculum analysis are critical for today's speech-language pathologist to be successful in schools practice, as is knowledge in case management, including the management of clients/students and other adults associated with clients/students such as aides, paraprofessionals, etc.

The Future: New Ventures-New Adventures

As we look into the future what are changes I anticipate to occur?

I expect to see increased partnerships between higher education and school districts.  What ever happened to "campus schools,"  the laboratories for practitioner training?  Will the concept have a resurgence?  School districts are legislated to develop comprehensive, professional development plans.  I anticipate we will see increased contractual agreements between school districts, state education departments and higher education to partner in accomplishing professional development.  As more states require continuing education and the accruing of CEUs for teachers and school personnel, I see higher education taking advantage of this opportunity to become providers.  There is already increased partnering with on-site speech-language pathologists and audiologists in the teaching of academic courses.  I anticipate this to move into shared clinical duties.  Perhaps schools and other health care settings will become the "university clinics" of tomorrow.

I expect to see school districts capitalize on technology available and develop distance "therapy".  Will we be there to develop the protocols?  To carry out the required research?

I expect the need for "Just-In-Time" (JIT) training modules to escalate.  School districts are often required to develop programs for certain populations as issues emerge.  Currently, autism and emotional disturbance occupy a great deal of human and monetary resources.  Speech-language pathologists often require "JIT" training as students with low-incidence disorders enter their caseloads.  Will our universities be the source of "Just-In-Time" modules?

Certainly the changing face of practice in educational settings poses challenges for our professions and the standards we establish.  We as the professionals, and we as the ones who prepare professionals, will be most successful if we adopt the concept embellished in Spencer Johnson's Who Moved My Cheese ( 1998).

        From: Who Moved My Cheese?
        Spencer Johnson

Selected References

ASHA.  (1999).  1999 Omnibus Survey: Caseload report: SLP.  Rockville, MD: Author.

Ehren, B. (February 2000) The role of the school-based speech-language pathologist vis-a-vis IDEA '97.  ASHA Website Professional Issues Forum.  Rockville, MD:
http://www.asha.org/students/professional_issues/index.htm
www.asha.org/students/professional_issues/index.htm

Frattalli. C. M.  (Ed.)  (1998).  Measuring outcomes in speech-language pathology.  New York: Theime.

Johnson, S.  (1998).  Who moved  my cheese?   New York: G. P. Putnam's Sons.

Logemann. J. (March 14, 2000).  What is evidence-based practice and why  should we care? The ASHA Leader, 5, 3.

National Commission on Excellence in Education (April 1983).   A nation at risk:  The imperative for educational reform.  Washington D.C. U.S. Government Printing Office.

National Education Goals Panel (1993).  Summary guide:  The national educational goal report-building the best.   (Publication number 1993-814-90195).  Washington, D.C.: U.S. Government Printing Office.

New York State Education Department (1999).   Request for proposals:   Intensive teacher  training program for speech-language pathologists.  Albany, NY: Author

New York State Education Department (October 14, 1999).  Definition of special education  services that may be provided to pupils with disabilities in a general education classroom  to qualify for an additional .50 weighting.  Albany, NY: Author
 http://stateaid.nysed.gov/pwdset.htm http://stateaid.nysed.gov/pwdset.htm

O'Neil, E.  (1993).  Health professions education for the future:  Schools in service to the nation.  San Francisco, CA: Pew Health Professions Commission.

P.L. 105-17, IDEA Amendments of 1997.

Will, M.C. (1986).  Educating children with learning problems:  A shared responsibility.  Exceptional Children, 52, 411-415.

U.S. Department of Education (1999). 34 CFR Parts 300 and 303:  Assistance to states for the  education of children with disabilities and the Early Intervention Program for Infants and  Toddlers with Disabilities.  Federal Register, 64, (48).  Washington: Author

Vector Research Inc. (September 30, 1999).  ASHA workforce study:  Final report.  Ann Arbor,   MI: Author