Breaking Up is Hard to Do: Dismissal from Speech and Language Services

As SLPs we are awesome at evaluation.  We are able to take multiple pieces of data such as standardized test scores, work samples, classroom observations, teacher reports, and parent reports and quickly determine if the student has a communication impairment.  We can easily identify what type of communication impairment they have and what goals we will work on to address the problem.  

When it comes to dismissals though, we are not as confident.  Because, really, how can you tell when the student is done? If you work in the medical or clinical area of our profession, the insurance eventually runs out.  Many parents stop the services when they have to pay out of pocket. Not so in the school system. Students in schools are with us from Kindergarten to 12th grade or longer if they receive post-high school services.  

With staff and funding cuts, we are often faced with making decisions about who continues to require speech and language services to access the curriculum and who does not.  Also, what about those students with articulation disorders who just can’t get that /r/ in place after 8 years of working on it? How do we make a good case for dismissal? Here are some tips:

1. Focus on the essential questions.  There are 3 questions you need to answer in order to determine if a student requires special education services: 1. Does the student have a disability? 2. Does the disability limit access to or progress in the general education curriculum? 3. Does this student need speech and language services to access the curriculum?  This is different from whether the student qualifies for services based on test scores.  You need to be able to answer yes to all 3 of these questions in order for the student to be eligible for special education services.
2. Standardized test scores are one piece of data.  A student’s score on a standardized language assessment or articulation assessment should not be the only data used to determine if a student requires speech and language services. It only answers the first of the 3 essential questions. Don’t forget to look at grades, attendance, work habits, other supports available, work samples, observations, teacher reports, student motivation to work on the goals, etc.
• For example:  Skyler is a 10th-grade student with language scores in the high sixties and low seventies.  Clearly, he has a language impairment based on these scores and if that is all we were using, he would definitely be getting speech and language services.  Let’s add a bit more data: Skyler also has a learning disability and is taking special education supported core academic courses. That means he pretty much gets special education support in all of his academic classes with the exception of History.  He is getting a lot of support for his language and learning disabilities within the classroom. Now let’s add another piece of data, grades. Skyler has all As and Bs in his classes including 2 general education electives and a C in his gen ed history class.  Let me repeat, a C in a very challenging gen ed class. In speaking with the history teacher, Skyler frequently asks for help with assignments and the teacher has been very good about supporting him. Now let’s add an observation of this student. Skyler has been observed in multiple classes to ask for help and using his study hour wisely.  He has been observed making flashcards on multiple occasions to study for upcoming tests and he has also been observed working with other students on assignments and quizzing each other before tests. Let’s add that this student has only 2 missing assignments and they were due to a recent absence due to illness. Skyler’s attendance is also excellent.  So, here is a student who is passing all of his classes and is fully accessing the curriculum given the supported academic classes. He is a hard worker, does his homework, and studies. Also, his therapy progress in recent months has been limited because he would prefer to stay in his study hour and study for tests rather than receive my services. While he is perfectly agreeable when I work with him, he has reported that he no longer wants the service.  If we go back to the question, “does this student need speech and language services to access the curriculum?” the answer is “no.” He has supports in place to meet his needs. If I had just looked at his standardized scores, I would have felt the need to keep him on the caseload until graduation but, with all the other data, I can’t make a case for continuing to provide services.
• Now let’s look at Philip.  Phil has a learning disability and a mixed mild expressive and receptive language impairment.  He was one of those that I was on the fence about doing a dismissal and left the decision up to the student who said that he still wanted the service.  He is very inconsistent in his school performance. Sometimes he does well, and sometimes he doesn’t. He has all gen ed classes with the exception of a special education supported Math class as Math is an area of weakness.  He is struggling the most in language arts, a class he is currently failing, and often misinterprets the writing prompts or does not use enough detail to write a quality essay. I made the decision to continue to support his language arts goals and assist him with clarifying language in the assignments as well as increasing his output and detail.  While he barely qualifies for speech according to test scores, he is not accessing the general education curriculum very well given his failing grade in LA. Unlike Skylar, he is not getting much support in his core academic classes. I decided to Keep Phil on in order to get him back on track.
3. Ask yourself the right question. Does the disability interfere with the student’s participation in the general education curriculum?
• Now let’s take a look at Tiffany.  Tiffany is a 9th grader with a learning disability and hearing impairment.  She also had a noticeable articulation disorder with errors on the /s/, /sh/, and /r/ sounds.  Her parents had recently taken her for an evaluation at a local hospital. Her scores on the standardized articulation assessment were in the impaired range.  The hospital therapist recommended continuing articulation therapy and suggested that some work on nasality be added to her other objectives. Thanks private therapist! So, there was one piece of data.  Let’s add my therapy data. Tiffany loved coming to speech and chatting me up but when it came to working on her errors, she just wasn’t interested. She didn’t really have a decent /r/, even using all the creative elicitation techniques.  She couldn’t really hear the difference either. In all the years of therapy, she had improved a lot and was intelligible but not perfect. Let’s add my observations of Tiffany. Tiffany was a talker. She talked all the time and was extremely social.  I eavesdropped on her out in the hallway talking with peers several times. I counted the number of times she was asked to repeat herself because someone didn’t understand her. Over several observations in the classroom and with peers, she was asked to repeat herself or had an incidence of miscommunication exactly 2 times over the 5 observations.  This indicated that, while she continued to have an articulation disorder, it was not interfering with her ability to participate at school. She was not reluctant to speak in class or to friends and they were able to understand her just fine. When I met with her mother, a school psychologist, I shared my data. She was disappointed as she, of course, wanted as much service for her daughter as she could get, but she agreed that it really didn’t interfere with her life.
• Contrast Tiffany to Angelo.  Angelo approached his counselor about getting speech therapy for his /r/ sound.  He had never had speech in his life but had a mildly distorted /r/. Like Tiffany, Angelo would come out in the impaired range as /r/ should have been in place at the age of 14.  Unlike Tiffany, Angelo avoided speaking in class due to his /r/ sound. He reported that a couple of peers had said something about his speech sounding funny. So, while Angelo was much more mildly impaired than Tiffany, it was having an impact on his education and socialization.  He was also highly motivated to work on his speech. Angelo was in, Tiffany was out.
4. You are not the only game in town.  As SLPs in the public school system, we are lucky to be part of a team.  Most students with significant disabilities have multiple professionals and multiple supports in place.  Language impairments, cognitive impairments, and learning disabilities can often be very intertwined. As students get older, sometimes support for a language impairment is best provided by a special education teacher in the classroom or resource room.  Most of the special education teachers that I know work on a lot of the same things that I do. They directly teach vocabulary, they work on comprehension, verbal expression, etc. If you can make a case that the supports and instruction are already being provided in the classroom then the student might not need your extra services to access the curriculum.  In addition, we don’t own pragmatic language disorders either. A good Social Worker can certainly handle teaching social skills as well as we can. The social worker and I would coordinate these services, she would take the students who knew social rules but needed practice applying them and I took the students who didn’t know social rules well or had a receptive language impairment along with the pragmatic impairment.
5. Plant the seed early and water it often.  When you start to see that a student is nearing the end of their speech therapy career, give the parents a heads up.  I usually make a phone call or send an email saying, “Lindsay has really made a lot of progress on her goals so far this year.  It looks like she may be ready for dismissal by the end of the year. Most parents are happy to hear this news and are just fine with it.  Others are not so fine with it. Some SLPs don’t like giving the parents advanced notice because parents can get really upset and start to panic.  Some will take their child and have a private evaluation done to add support to their case or start calling your colleagues or supervisor to complain about you.  I say, bring it on. I don’t mind the input of other professionals in my field and I am happy to consider their input in making my decision. I have found that the direct approach is much better than trying to pull a fast one on the parent.  Trying to sneak in a dismissal during the IEP is just not fair to the parents and will come back to haunt you in the future. Not only will the parents not trust you, but they will also distrust the rest of the team as well. Often, by the time the IEP comes around, the panic has died down and the parent is able to hear what you are saying.  Sometimes I even start warning the year before the student is ready for dismissal by saying, “Lindsay probably won’t need speech forever. She will probably be dismissed in the next couple of years.” The more warning the better!
6. Don’t be a wuss!  Once you have collected your data and consulted the team, stand by your decision.  Repeat these words, “the data just doesn’t support a continued need for this service.”  Of course, you should listen to the parents' concerns and consider any data that they add to the discussion.  Once or twice the parents have pointed out a skill that was needed that I hadn’t identified in my assessment and I did keep the student on to address that skill.  And if the parent has a valid piece of data, you absolutely should consider it. Most parents who disagree, however, do not have a valid reason for continuing the service. They say things like, “I just wish you would keep him.  Just for one more year.” A wish is not data. This is where therapists start to cave. “OK fine. One more year,” we say. One more year and then what? Believe me, it won’t be an easier conversation next year. And don’t be an ass and pass the buck on to the therapist at the next school.  Nothing makes me madder than getting a kid who clearly doesn’t need speech and having to take time out of my week to provide services that are a waste of their and my time just because you were too spineless to stand up to the parent. Just be kind and firm and most parents will not fight you on it, even the really prickly ones.  But, if you are wishy-washy about it, they will smell your fear.  
7. A word about consult services.  Many SLPs offer up consult services when the parent is really making a fuss over a dismissal. I would caution you to continue to stand by your data and move forward with a dismissal if that’s what you believe is the right thing to do. Consult services should be used sparingly.  If you decide to offer consult services, be VERY CLEAR about what that would entail. Spell out exactly what you will be doing for the student and make sure the parent understands and agrees. While we have the best of intentions when we are sitting in the meeting, we all get busy and the consult students often go by the wayside.  We get to the end of the month and think, s**t, I didn’t consult on Steve this month. So, we run into Steve’s teacher in the bathroom and say, “how’s Steve doing?” That’s our consult, a one second interaction with the teacher in a public restroom. Trust me, as someone who has had to sit with some of the most aggressive and unpleasant advocates, make a consultation plan and stick to it.  Also, document everything you do to support that student. If you don’t, it will come back to bite you in the ass.
8. What about the old articulation kids who aren’t making progress?  This is a really tough one for SLPs.  If you do your prep work appropriately, you should be able to make a compelling case for dismissal.  This will involve looking back at the student’s old IEPs if you can. Look at the number of years the student has had services for articulation. Knowing the number of years of therapy for articulation will be important to show the student has perhaps hit a plateau. If she has had service for 8 years, perhaps we have taken them as far as they can go. Next, look at the service times and note any changes over time, Looking at the service time over the years can give a clue about whether the student was given sufficient time to work on the goals.  If the previous therapists are still around, ask them about whether services were delivered at the rate listed on the IEP. There may have been frequent absences or behavioral problems that hindered service delivery.  If that is the case, you may want to try a short period of increased service time to see if it improves progress. After that, look at the goals as well to see if they start to repeat themselves. The goals over time will give a huge clue as to the progress being made.  If the goals have been recycled multiple times, then we know the therapy is likely not working. Lastly, If you can get copies of progress reports, review those as well and see how much progress has been made over time.  Be prepared for the fact that this student may not have had adequate therapy over the years or an adequate amount of service time and practice to make gains. Also, were multiple approaches attempted to help this student or was he given the same approach all those years?  This might be a time to do a little research to see if there are new techniques or elicitation strategies that might help. A trial of more intensive intervention using new strategies would be worth a try before throwing in the towel. Also, institute some kind of home practice that the parent needs to sign off on.  This may help the progress and indicate the parents' true level of commitment to improving their child’s speech. This intervention will definitely give you data to suggest that continued therapy would be useful or just a waste of the student’s time. Let the parent know of your concerns and that you are trying some new things to see if any further progress can be made. Make sure that the parent understands that a dismissal is possible.  
• This brings me to Liam.  Liam is a student with a significant emotional impairment who also has cognitive scores in the borderline cognitive impairment range. He has a distorted /r/ and is unable, after many years of trying, to make a decent production.  His speech is difficult to understand until you get to know him. In addition to /r/, he leaves off /s/ and /z/ endings on words including when they are grammatical markers like in the word cookies. The other problem, he talks really fast.  When he speaks slow enough, people can understand most of what he says. And, like our pal Tiffany from the earlier example, he really doesn’t care about his speech. He talks all the time and participates in class. The teachers often have to ask him to repeat, which he is willing to do without becoming angry or shutting down.  When I started with Liam, he hadn’t had adequate services due to his frequent behavioral outbursts. The previous therapist did her best to provide services but he was often in crisis when she showed up to provide services. I tried upping the service time. I tried using different assessments to get to the root of the problem. I tried pacing techniques, worked on his grammar, and many other strategies to help him along.  The bottom line is, he just doesn’t care about his speech and isn’t very motivated to change it. He is good for about 5 minutes of pacing and then he goes right back to his rapid pattern. I will be dismissing him this fall. The parents have been warned that this might be it. I will be bringing my report describing everything that has been done for their son and also his lack of motivation. I will also note that he does not notice an impact at school. The teachers will certainly tell you that they don’t understand him all the time but that when he repeats slower, they can get the gist of what he is saying.  I will fully admit in the report that he continues to have an articulation disorder and that it does have a mild impact on his ability to be understood by teachers. I will note that his progress has tapered off and he is not benefiting from the service at this point. I am sure that they will be disappointed but they will not be surprised and they will understand.  

Dismissals are hard especially when you see the progress toward goals begin to slow down or stop completely.  It’s hard when you see the student shrink down in her chair when she sees your face at the door. It’s hard when you are facing down an assertive parent who wants as many services as possible for their child for as long as possible. It’s hard when there is no definitive sign that the student is done with speech. So, take a breath and if you can collect all of the above data, you will start to see it lean either toward a dismissal or continuation.  Then look the parent in the eye with confidence in your voice and break up with them. It will be OK.