We are going to be talking about a variety of different service delivery options that can be used in your school-based practice. I love the current job that I have because I get to interact with so many SLPs. I enjoy CF supervision and mentorship as well as the ability to have clinicians bring new, wonderful ideas that give me some things to think about.
The information in this course may be a review. However, I would like it to be a way to refocus your attention on service delivery in the schools and to think beyond the doldrums of our daily lives as SLPs and all that is thrown at us on a weekly basis. Use this as an opportunity to focus your attention back on the students and their needs. I know that, personally, sometimes it seems the students are the last thing I think about during the week. I have had to make an effort to do a better job about that because the students are what it is all about.
My one disclosure is that I am being paid by speechpathology.com for this course and I do not have any non-financial disclosures.
What Do the Laws Say?
School-based clinicians need to be mindful of a few items when looking at service delivery for students. We must always be aware of what the law states about services in the public school for children who qualify for special education services, which include speech services. In some states speech may be a standalone service while in other states it is considered to be a secondary service.
Typically, as special educators, SLPs adhere to IDEA which requires students with disabilities to be served with their non-disabled peers to the maximum extent appropriate. The objective behind IDEA is to make education free and appropriate for every single student, regardless of their level of understanding, their level of cognition or their level of participation. Students should be educated in the least restrictive environment possible and with a group of their peers because students learn much more from their peers than they do from us.
In keeping with IDEA, I always try to be very mindful of what the needs are for the student that I am seeing for services. Perhaps they are not doing well or they are not progressing as I thought they would. Keep in mind when planning for your students that there are legal obligations to consider least restrictive environment, the needs of the student and how best to meet those needs.
In addition, the Disability Act of 2008, put a greater emphasis on least restrictive environment. It encouraged the adoption of new approaches that promised better student outcomes. We all know student outcomes are a big thing right now. We also know that in the educational realm there are many standardized assessments that are required by the states now. No matter where you live, you will most likely help administer state standard assessments or you will be getting children ready to take and pass those assessments.
What Guidance Does ASHA Provide?
Because education is very different from the medical setting, it’s important to be aware of the educational parameters and what occurs in the educational environment. ASHA provides a wealth of great information. Many of you are already familiar with ASHA’s position papers and the suggestions they make for school-based SLPs. One of the things that is ever present in the information that ASHA provides is that treatment of speech disorders is a very dynamic process. Meaning, it is going to change with the level of needs of the student that you serve. Your services are going to change over time because of the student's ability to progress, or, in some cases, regress.
Continuum of Service Delivery
Let's look first at the continuum of service delivery. This is always a hot button topic. The content that I share in this course is general in nature and does not suggest that all school districts adhere to it or, that if they don’t, they are not doing things correctly. All states do things differently, in fact even school districts within a state will do things differently.
When a student qualifies for special education services, that opens up a continuum of services from consultative services where you're only providing information to classroom teachers so they can assist the student, to the other end of the spectrum where there are children in a self-contained classroom with other special education students the majority of the day. That is the least restrictive environment continuum that we are always looking at and determining which service delivery matches what is best for the student.
In speech-language pathology there are traditional pull-out services which can be individual, paired or small group. However, even in a pull-out traditional model we should be providing services that are built around the curriculum. The materials and activities have to have an educational basis and we must understand what is going on in those educational environments in order to be successful in helping students in the educational setting.
Sometimes, a push-in or classroom-based model is used. I don’t like the term “push in” because I think of it as pushing my way in a place that I shouldn’t be or I am forcing myself on someone who doesn’t want me in their classroom. I prefer to use the term “classroom-based,” “collaborative,” or “integrated.” I try to stay away from “push in” when speaking with classroom teachers or administrators. Rather, we should look at this classroom-based or collaborative sessions, either individual, small group, or large group. You will understand what I mean by individual, small group, or large group when we start talking about classroom-based or collaborative services.
There are also non-academic settings such as a lunch room, playground, specials (e.g. art, music, physical education) or special interest clubs. Some schools have social groups or lunch buddy groups.
Therapy can be conducted in one or any combination of all the service delivery models to determine what is best for the students you are serving. I combine settings quite a bit. With high school students I do a lot of community-based therapy where some of my services are out in the community with the students if they are on job sites or if they are preparing for job interviews. If a student communicates with an augmentative communication device, I will make sure that the augmentative communication device is appropriate for the work setting that they are in.
I also do a lot of self-contained classrooms where all of the students might have autism or they may have more functional skills that they are working on. Their track may not be academically relevant so much as it is practical and functional for them as they grow and develop. We are trying to get them ready to go out into the real world after graduation.
There are also consultative services. The states have many differing opinions on consultative services. Some school districts say that consultative services are not appropriate and will not write them into an IEP. Obviously wherever you work you need to follow their protocols. But, know that there are many different things that can be done in terms of consultation of a student’s needs and progress on AAC devices or strategies that can enhance community, communication, and participation, etc.
Pull Out Services
Let's take a look at the service delivery models in more detail. For the first 15-20 years of my career, the only service delivery model used in schools was pull-out services where I would make numerous trips to the students’ classrooms and take them back to our room to do very specific, intensive, private sessions. Skills are taught to the students in a very distinct and intensive way. Many clinicians only do pull-out services. There are many clinicians who have a very large caseload and they can’t figure out how to fit their caseload into a variety of different service delivery models. I, too, have been in that situation.
There are some instances when pull-out services can be appropriate. The pros for this model are that services are intensive and more private. Pull-out is a great opportunity to initiate the nuts and bolts of a basic goal and objective that is listed on the IEP. This model is great for introducing isolated skills. Pull-out services are sometimes extremely necessary for certain students who may be very self-conscious about their communication difficulties. For example, a child who stutters may be very anxious in a large group setting which causes them to stutter more. A child with central auditory processing disorder may have difficulty focusing in a larger group setting or classroom because of issues such as background noise. They may need to be seen one-on-one or in a very small, private situation.
As the SLP, you are the one who knows how to dissect that student’s areas of difficulty besides their communication disorder in order to decide what environment works best for them. What you need to think about with your service delivery is if it is necessary to pull the student out. Are there some activities that have to be in the therapy room or are there other avenues and environments where the student can get more educationally relevant information? The classroom is typically the best environment to determine what is going on with a student.
I always like to ask myself if I am doing the right thing by pulling the student out or am I doing something that might be detrimental. There are a few cons to using pull-out services. They are always separate and apart from the educational setting and keep the students from the teacher, the curriculum and their non-disabled peers.
Sometimes the activities that I plan are not connected to the student's daily activities. They don't really lend themselves much to carry over when the child goes back to the classroom because I've taught the skill with materials that they only see in my room. I've taught the child strategies that they only use in the therapy room. Pull-out treatment alone sometimes does not promote those skills of carry over and generalization. There is a lot of research to support those findings.
Additionally, you can't effectively replicate interactions and activities commonly found in a classroom. I do a lot of role playing in therapy with older students, particularly older students who have autism. Some of the students with higher functioning Asperger will sometimes say, “I appreciate what you're trying to do, but this is not how this really works in my world.” They will be really honest with me about that. It's just really hard to replicate those situations when you're away from their real lives in school and what really happens.
Students struggle to make successful connections. Obviously if these children were able to generalize skills immediately, they probably wouldn't be in special education in the first place. We need to look at the whole child to determine if we are doing more harm than good. Sometimes, I go into an IEP meeting and I am so excited to share with the parents all of the great things that their son or daughter are doing and the teacher says that she isn’t seeing any of that happening in the classroom. That is what I mean by ‘disconnect’. Our students do well with us but when we send them back to the classroom their improvements are evident to the parents or the classroom teachers. That's what is meant by making successful connections.
The biggest obstacles with pull-out therapy that I have found include working on the student’s identified challenges in isolation. It doesn't always provide me with any information from the classroom teacher or allow me to provide information back to the classroom teacher. Also, I am working on challenges that are not found in the educational setting and I don’t have the same materials as the classroom. With pull-out services, my hope is that the student’s skills will carry over to other settings. Unfortunately, sometimes they don’t.
I have changed my mindset from always using a pull-out model to implementing more integrated or collaborative services first.
It is well documented in the research that this type of service delivery results in better carryover, more student progress in academics, more consistent progress over time, better relationships with the classroom teachers and numerous team building opportunities.
Collaborative services have provided the opportunity to learn the vocabulary and other aspects of the curriculum that teachers are implementing in the classroom. They have some outstanding ideas in terms of accommodations and strategies and have taught me much more than I could learn by myself. There are many master’s level teachers in the classrooms and I always love to learn from those individuals. Likewise, some teachers are either brand new to the profession or maybe they have been teaching for a long time and don't really have the energy anymore to change what they are doing. If you can approach them with, “I could really use your help with this,” then you might make some small changes in the way they teach and you can build some really nice relationships that way.
Research also shows that integrated services are the most effective and relevant way to teach curriculum vocabulary. Because of some of the points I mentioned earlier, a child can’t be taught vocabulary in isolation and then be expected to use those new vocabulary words in academic situations.
It can be very difficult to collect data with a collaborative service delivery model. When I was in school, we were taught to take data on every single item every single day or you are not doing your job correctly. With integrated services, you can’t collect data in that way. It is collected in the form of activities the students do and then are graded afterwards. Data can also be collected in the form of a student portfolio or work portfolio. I've had to come out of my comfort zone a lot in order to buy into what's going on in the educational activities in the classroom, and likewise to get teachers and parents to buy into it. Parents often think if the child is not pulled out for services then they are not being seen.
There have been times that I felt like a tutor in the classroom or a glorified paraprofessional. I am not discounting paraprofessionals; they are very necessary in an academic setting. By “glorified paraprofessional” I mean that I have felt like have sat with a student but didn’t really contribute anything.
Sometimes integrated services are not supported by the special education department or by the school administrator. If that is the case, you have some challenges. In addition to just making the system work, there can be some challenges in changing people's minds about what they are seeing.
Another big challenge when I first started doing integrated services is not knowing anything about the curriculum or the state standards. I really had to do my homework in those areas. It's okay if you don't know anything about those areas. You just need to understand what you don't know and then go find information about it.
The last con is scheduling issues. You may have one student in one class and another student in another class, your caseload is extremely large, etc. Later in the course, I am going to share some things that you can do to help with those issues.