Hot Topics: A Report From the Task Force on Fluency Services in the Schools

Hot Topics: A Report From the Task Force on Fluency Services

in the Schools

ASHA CONVENTIONASHA CONVENTION

Washington, D.C. 2000Washington, D.C. 2000

Presented byPresented by

Kristin A. Chmela M.A. CCC-SLP Lisa Trautman, Ph.D CCC-SLPKristin A. Chmela M.A. CCC-SLP Lisa Trautman, Ph.D CCC-SLP

Ellen Bennett Ph.D, CCC-SLPEllen Bennett Ph.D, CCC-SLP Nina Reardon M.S. CCC-SLP Nina Reardon M.S. CCC-SLP

Marybeth Allen M.A. CCC-SLPMarybeth Allen M.A. CCC-SLP Kathleen Strimple, M.S. CCC-SLP Kathleen Strimple, M.S. CCC-SLP

Louise Heite Louise Heite

Task Force on Fluency Services in the Schools

Current charge based upon:Current charge based upon: Reauthorization of the Individuals with Reauthorization of the Individuals with

Disabilities Education Act (IDEA)Disabilities Education Act (IDEA) Changing role of the school-based speech-Changing role of the school-based speech-

language pathologistlanguage pathologist Recognizing the impact of these issues on Recognizing the impact of these issues on

the diagnosis and treatment of children who the diagnosis and treatment of children who stutter in the schoolsstutter in the schools

Hot Topics:

Purpose of presentation : To provide guiding principles related Purpose of presentation : To provide guiding principles related to stuttering therapy in the school setting in the following to stuttering therapy in the school setting in the following areas:areas:

Entrance and exit criteria for fluency Entrance and exit criteria for fluency Developing fluency goals that are relevant to the general Developing fluency goals that are relevant to the general

curriculumcurriculum Caseload management and service delivery issues Caseload management and service delivery issues

Reauthorization of the IDEA regulations: Marked a renewed commitment to improving Marked a renewed commitment to improving

quality of services to children with disabilitiesquality of services to children with disabilities Allowed students greater access to the general Allowed students greater access to the general

curriculum curriculum Created changes in who will qualify for speech Created changes in who will qualify for speech

and language services, how IEP’s are developed, and language services, how IEP’s are developed, and the manner in which services will be deliveredand the manner in which services will be delivered

IDEA regulations, cont.

Qualified children for service based on Qualified children for service based on educational impact. This impact, however, educational impact. This impact, however, included activities beyond the academic classroom included activities beyond the academic classroom experience. (non-academic and extracurricular)experience. (non-academic and extracurricular)

Specified that clinicians may advocate for Specified that clinicians may advocate for preferred practicespreferred practices

Included parents as providing input into the Included parents as providing input into the evaluationevaluation

Aspects of stuttering to consider: Stuttering is a multidimensional, nonlinear, Stuttering is a multidimensional, nonlinear,

dynamic disorder. (Smith & Kelly, 1997)dynamic disorder. (Smith & Kelly, 1997) Stuttering is a heterogeneous disorder Stuttering is a heterogeneous disorder

which includes affective, cognitive, and which includes affective, cognitive, and behavioral components. (Guitar, 1998)behavioral components. (Guitar, 1998)

Teachers are more likely to form Teachers are more likely to form misperceptions about children who stutter misperceptions about children who stutter in their classrooms. (Lass et. al, 1992; in their classrooms. (Lass et. al, 1992; Crowe and Walton, 1991)Crowe and Walton, 1991)

Additional aspects to consider: Clinicians have reported feeling less secure Clinicians have reported feeling less secure

when treating individuals with stuttering when treating individuals with stuttering disorders. (Kelly et al., 1997)disorders. (Kelly et al., 1997)

Changes in academic and clinical Changes in academic and clinical preparation standards for fluency disorders preparation standards for fluency disorders may result in a masters level graduate may result in a masters level graduate treating children who stutter without ever treating children who stutter without ever having a course or clinical preparationhaving a course or clinical preparation

Entrance and exit criteria

States vary dramatically in their eligibility States vary dramatically in their eligibility criteria for speech-language servicescriteria for speech-language services

Entrance and exit criteria must now Entrance and exit criteria must now coincide with the impact that the disorder coincide with the impact that the disorder has on educational performance.has on educational performance.

A Brief Review of IDEA: eligibility

Eligibility decisions based on etiology, severity, Eligibility decisions based on etiology, severity, prognosis, government regulationsprognosis, government regulations

Discrepancies exist in definitions, assessment Discrepancies exist in definitions, assessment methods, and eligibility criteriamethods, and eligibility criteria (Apel & Hodson, 1994; (Apel & Hodson, 1994; Nye & Montgomery, 1995)Nye & Montgomery, 1995)

Criteria are set at the state levelCriteria are set at the state level Part B requires placement when there is an Part B requires placement when there is an

adverse educational impact (AEI)adverse educational impact (AEI) ““Adverse impact” is not defined in legislation Adverse impact” is not defined in legislation

Adverse Educational Impact (AEI) Cannot be limited to discrepancy in age/grade Cannot be limited to discrepancy in age/grade

performanceperformance Must be determined on an individual basisMust be determined on an individual basis Includes academic and nonacademic areasIncludes academic and nonacademic areas

General curriculum (e.g., reading, math)General curriculum (e.g., reading, math) Nonacademic curriculum (e.g., art, P.E., music)Nonacademic curriculum (e.g., art, P.E., music) Extracurricular activities (e.g., sports, clubs)Extracurricular activities (e.g., sports, clubs)

Determining educational relevance: Academic: ability to benefit from the Academic: ability to benefit from the

curriculumcurriculum Social: ability to interact with peers and Social: ability to interact with peers and

adultsadults Vocational: ability to participate in Vocational: ability to participate in

vocational activitiesvocational activities

Academic impact:(Lee County, Florida 1995)

Areas impacted by:Areas impacted by:Reading/math/language arts/otherReading/math/language arts/other

Impact documented by:Impact documented by:Academics below grade levelAcademics below grade levelDifficulty with language based activitiesDifficulty with language based activitiesDifficulty with auditory comprehensionDifficulty with auditory comprehensionDifficulty communicating information orally***Difficulty communicating information orally***

Social Impact

Areas impacted:Areas impacted: Communication problem interferes with listeners’ Communication problem interferes with listeners’

understanding***understanding*** Difficulty maintaining or terminating verbal Difficulty maintaining or terminating verbal

interactions***interactions*** Student experiences teasing from peers***Student experiences teasing from peers*** Student demonstrates fear/embarrassment***Student demonstrates fear/embarrassment*** Other Other

Vocational impact

Impact on job related skills/competencies:Impact on job related skills/competencies: Difficulty following directionsDifficulty following directions Inappropriate commentsInappropriate comments Difficulty asking/answering questions***Difficulty asking/answering questions*** Other***Other***

IDEA Assessment Requirements & Stuttering Use a variety of tools and strategiesUse a variety of tools and strategies

More than just speech sampling & More than just speech sampling & analysisanalysis

Obtain relevant and functional information Obtain relevant and functional information about the childabout the child Not just where they’re stuttering or how, Not just where they’re stuttering or how,

but how it affects thembut how it affects them

IDEA Assessment Req’s (cont.)

Information from parents & teachersInformation from parents & teachers Participation, perceptionsParticipation, perceptions

No single criterion should be used to determine No single criterion should be used to determine eligibilityeligibility Motor behavior - separate criteria or one Motor behavior - separate criteria or one

criterion?criterion? Must include cognitive and affective factorsMust include cognitive and affective factors

Heavy emphasis on behavioral factors onlyHeavy emphasis on behavioral factors only

The Assessment Process

Stage I:Stage I: Establish that a disorder is present Establish that a disorder is present without respect to severity or impactwithout respect to severity or impact Concerned with presence/absence of disorderConcerned with presence/absence of disorder Guiding question:Guiding question: Does the child stutter? Does the child stutter?

Stage II:Stage II: Determine whether the condition has an Determine whether the condition has an AEIAEI Concerned with child’s ability to function in Concerned with child’s ability to function in

educational settingeducational setting

Assessment process (cont.)

Must include information from parents, Must include information from parents, teachers, observation across settings, teachers, observation across settings, analysis of samplesanalysis of samples

Independent of severityIndependent of severity

Guiding question:Guiding question: Does the stuttering Does the stuttering cause an AEI?cause an AEI?

Assessment process (cont.)

Stage III:Stage III: Decide whether student needs services Decide whether student needs services in order to participate appropriately in the general in order to participate appropriately in the general curriculumcurriculum

Consider academic, nonacademic, and Consider academic, nonacademic, and extracurricular areasextracurricular areas

Guiding question:Guiding question: Does this child need Does this child need stuttering therapy to increase participation in stuttering therapy to increase participation in the curriculum?the curriculum?

Professional Judgment

Can be used by team when student does not Can be used by team when student does not meet eligibility criteria but team believes meet eligibility criteria but team believes there’s an AEIthere’s an AEI

Need to document both formal and informal Need to document both formal and informal measures used to make the decisionmeasures used to make the decision

Our Review of Entrance/Exit Criteria Limited sample of criteria from California, Limited sample of criteria from California,

Illinois, Kansas, Maine, Nevada, & New MexicoIllinois, Kansas, Maine, Nevada, & New MexicoFindings:Findings: Guidelines/requirements for assessment were Guidelines/requirements for assessment were

rarely definedrarely defined No suggestions/limited direction about what to No suggestions/limited direction about what to

document beyond speech sampledocument beyond speech sample Most districts had entrance criteria but few had Most districts had entrance criteria but few had

exit criteriaexit criteria

Entrance criteria

Identified 44 different criteria, falling into one of 6 Identified 44 different criteria, falling into one of 6 categories:categories: Cognitive: beliefs/perceptionsCognitive: beliefs/perceptions Affective: EmotionsAffective: Emotions Linguistic: Linguistic units or behaviorsLinguistic: Linguistic units or behaviors Motor: Form, frequency, duration, accessory Motor: Form, frequency, duration, accessory

behaviorsbehaviors Social: AEISocial: AEI Other: age, chronicity, history, etc.Other: age, chronicity, history, etc.

Percentage of criteria across possible categories of Cognitive, Affective, Linguistic, Motor, Social, and Other Factors

0

5

10

15

20

25

3035

40

45

50

Cognitive Affective Linguistic Motor Social Other

Entrance criteria (cont.)

Cognitive, affective, and linguistic components Cognitive, affective, and linguistic components were a small percentage of those documented for were a small percentage of those documented for eligibility (approx. 7%)eligibility (approx. 7%)

AEI was specifically defined in less than half of AEI was specifically defined in less than half of criteria reviewedcriteria reviewed

Motor (50%) and Other (25%) were heavily Motor (50%) and Other (25%) were heavily emphasizedemphasized

Less than 10% stated that Professional Judgment Less than 10% stated that Professional Judgment was an optionwas an option

Specific Motor Criteria by percentage

0

5

10

15

20

25

30

35

40

45

Form Frequency Physiology Duration Accessory

Specific “Other” Criteria by percentage

0

5

10

15

20

25

30

35

Age CrryOvr Hist. Chron. Devel. Neuro

Entrance criteria (cont.)

IDEA states that decisions regarding eligibility IDEA states that decisions regarding eligibility should not be predetermined by severity cut-off should not be predetermined by severity cut-off scores or disability categoryscores or disability category Not an individualized decisionNot an individualized decision

Can be interpreted to mean that heavy emphasis Can be interpreted to mean that heavy emphasis on motor behavior is not individualizedon motor behavior is not individualized Any criteria that includes a frequency or Any criteria that includes a frequency or

severity guideline may be questionableseverity guideline may be questionable

Task Force Guidelines: Entrance Criteria1. Less emphasis on motor behaviors1. Less emphasis on motor behaviors

2. Increase emphasis on affective and 2. Increase emphasis on affective and cognitive components of the disordercognitive components of the disorder

3. Consider affective and cognitive 3. Consider affective and cognitive components as aspects of severitycomponents as aspects of severity

Guidelines for Entrance Criteria, cont.4. Specifically require other measures beyond 4. Specifically require other measures beyond

speech sampling/observation of speech speech sampling/observation of speech behavior across multiple environmentsbehavior across multiple environments

5. Document AEI beyond classroom 5. Document AEI beyond classroom participationparticipation

IDEA & Exit Criteria Students should be dismissed when:Students should be dismissed when:

All objectives have been met and no additional All objectives have been met and no additional intervention is warrantedintervention is warranted

Parent requests exitParent requests exit Intervention no longer results in measurable Intervention no longer results in measurable

benefitsbenefits Child is unwilling/unmotivated and efforts to Child is unwilling/unmotivated and efforts to

address motivation have been unsuccessfuladdress motivation have been unsuccessful Extenuating circumstances warrant Extenuating circumstances warrant

discontinuationdiscontinuation

Exit criteria (cont.)

Disorder no longer impacts educational Disorder no longer impacts educational performanceperformance

Child no longer needs services to Child no longer needs services to participate in general curriculumparticipate in general curriculum

Our Review of Exit Criteria

Only 25% of districts with entrance criteria Only 25% of districts with entrance criteria had exit criteria for stutteringhad exit criteria for stuttering

““No longer presents AEI” was major factor No longer presents AEI” was major factor for exitfor exit

Parent/teacher perceptions were also Parent/teacher perceptions were also includedincluded

Our review (cont.) Some of the exit criteria were inconsistent with Some of the exit criteria were inconsistent with

entranceentrance E.g., Students considers self a normal speaker E.g., Students considers self a normal speaker

-- student’s perception was not part of entry -- student’s perception was not part of entry criteria for this same districtcriteria for this same district

None of the exit criteria recognized None of the exit criteria recognized chronicity/relapsechronicity/relapse E.g., Disfluencies have been remediatedE.g., Disfluencies have been remediated This needs to be considered when determining This needs to be considered when determining

“lack of progress” and “low motivation”“lack of progress” and “low motivation”

Task Force Guidelines:Exit Criteria1.1. Mirror those used for entrance Mirror those used for entrance 2.2. Document that no intervention is Document that no intervention is

warranted for all aspects of stuttering warranted for all aspects of stuttering problem, not just motorproblem, not just motor

3.3. Exit criteria consider chronicity/relapseExit criteria consider chronicity/relapse4.4. Provide for a continuum of support Provide for a continuum of support

services services Not just direct interventionNot just direct intervention

Developing Relevant IEP GoalsPOINTS:POINTS: Goals typically have been therapeutically focused Goals typically have been therapeutically focused

and profession specificand profession specific Teachers did not participate in the development of Teachers did not participate in the development of

IEP treatment goalsIEP treatment goals Speech-language pathologists now need to Speech-language pathologists now need to

“retool” their knowledge base to identify the “retool” their knowledge base to identify the communicative demands of the curriculum and to communicative demands of the curriculum and to assess what extent the curricular access is assess what extent the curricular access is impaired. (Shulman & Apel, 2000).impaired. (Shulman & Apel, 2000).

IEP requirements

Must:Must: Consider the child’s individual needsConsider the child’s individual needs Change as the child’s needs changeChange as the child’s needs change Discuss present levels of performanceDiscuss present levels of performance Include Annual goalsInclude Annual goals Include benchmarks or objectivesInclude benchmarks or objectives Consider other factorsConsider other factors

IEP requirements:

““Some children have educational needs Some children have educational needs resulting from their disability that are not resulting from their disability that are not directly related to what is thought of as directly related to what is thought of as “general curriculum.” (ASHA 2000)“general curriculum.” (ASHA 2000)

On an On an individual basisindividual basis the team determines: the team determines:

1. How the child will be involved in the 1. How the child will be involved in the general curriculumgeneral curriculum

IEP requirements, cont.

What needs resulting from the disability What needs resulting from the disability must be met to facilitate such participationmust be met to facilitate such participation

Whether there are other needs resulting Whether there are other needs resulting from the disability that must be metfrom the disability that must be met

What services must be included in the IEP What services must be included in the IEP to address these needsto address these needs

Considering the student’s communication needs What are the communicative demands, needs, and What are the communicative demands, needs, and

opportunities of the child?opportunities of the child? Does the child have the needed skills and Does the child have the needed skills and

strategies to meet the demands across relevant strategies to meet the demands across relevant contexts?contexts?

Does the student communicate appropriately and Does the student communicate appropriately and effectively given the opportunity?effectively given the opportunity?

(Council for Exceptional Children)(Council for Exceptional Children)

Task Force Guidelines: Developing IEP Goals1. Begins with teacher & administrator 1. Begins with teacher & administrator

educationeducation about the nature of stuttering about the nature of stuttering problems in children (see references)problems in children (see references)

2. Communicative competencies must be 2. Communicative competencies must be explored with explored with individualindividual teachers teachers

Guidelines, cont.

3. Recognize the nature of treatment the child 3. Recognize the nature of treatment the child currently needs currently needs

4. Relate stuttering treatment to the 4. Relate stuttering treatment to the curriculum:curriculum:

Guidelines, cont.

Academic material can be the stimuli in Academic material can be the stimuli in which skills are taughtwhich skills are taught

Strategies to teach skills in treatment can Strategies to teach skills in treatment can parallel classroom learning strategiesparallel classroom learning strategies

Oral communication skills utilized across Oral communication skills utilized across the curriculum in the classroom and other the curriculum in the classroom and other school environmentsschool environments

Guidelines, cont.

5.5. Consultation from a fluency specialist Consultation from a fluency specialist may be deemed appropriatemay be deemed appropriate

6.6. Aspects of stuttering therapy can be Aspects of stuttering therapy can be integrated into the classroom and benefit integrated into the classroom and benefit all students.all students.

Service Delivery Issues related to the IDEA reauthorization: Service delivery is a dynamic conceptService delivery is a dynamic concept No one service delivery model should be No one service delivery model should be

used exclusively during interventionused exclusively during intervention All service delivery models should include All service delivery models should include

collaborative consultation with otherscollaborative consultation with others IDEA regulations should result in more IDEA regulations should result in more

integrated service delivery modelsintegrated service delivery models

National Study: School Based Services (Peters-Johnson, 1998)

Mean session type per week:Mean session type per week:14 individual14 individual22 group22 group7 classroom7 classroom

Average # of group participants:Average # of group participants:4 children4 children

National Study, cont.

Stuttering service delivery:Stuttering service delivery:

86% Pull-out86% Pull-out

6% Collaborative-consultative6% Collaborative-consultative

5% Classroom based5% Classroom based

1% Resource room1% Resource room

2% Self-contained2% Self-contained

““The days are over for speech-language The days are over for speech-language pathologists to provide their servicespathologists to provide their services

solely using a “pull-out” model of solely using a “pull-out” model of

service delivery.” service delivery.”

(Shulman & Apel, 2000)(Shulman & Apel, 2000)

NOMS Data Report

Obtained “dismissal” data on 547 studentsObtained “dismissal” data on 547 students Most students received intervention in pull-Most students received intervention in pull-

out groups, regardless of disorderout groups, regardless of disorder Caseload size ranged from 25-104Caseload size ranged from 25-104 Service delivery models related to number Service delivery models related to number

of students on a clinician’s caseloadof students on a clinician’s caseload

NOMS Data Report, cont.

Increased caseload size =Increased caseload size = Shift from individual to group treatmentShift from individual to group treatment Increase in size of treatment groupsIncrease in size of treatment groups

Individual treatment “was unheard of”Individual treatment “was unheard of” Students on smaller caseloads were more Students on smaller caseloads were more

likely to make measurable progresslikely to make measurable progress

Changes enacted by the IDEA 97 related to service delivery:

If the pull-out model is deemed appropriate, If the pull-out model is deemed appropriate, it should be an integrated, content-based it should be an integrated, content-based approach focused on the classroom in terms approach focused on the classroom in terms of curriculum, learning processes, and of curriculum, learning processes, and concepts.concepts.

Types of Service Delivery

MonitorMonitor Collaborative consultationCollaborative consultation Classroom basedClassroom based Pull-outPull-out

Task Force Guidelines: Service DeliveryScheduling and grouping considerations:Scheduling and grouping considerations: Should take into account the non-linearity, Should take into account the non-linearity,

dynamic nature of the problemdynamic nature of the problem

Should take into account the ability to Should take into account the ability to incorporate other professionalsincorporate other professionals

Service Delivery Guidelines, cont. Should consider grouping children based on Should consider grouping children based on

curricular relevance of the stated IEP goalscurricular relevance of the stated IEP goals

Should take into account the adverse Should take into account the adverse educational impact educational impact

Building Advocacy:

Do we make stuttering fit the system Do we make stuttering fit the system or do we change the system to fit or do we change the system to fit

the problem of stuttering?the problem of stuttering?